M 


OPERATIVE  DENTISTRY. 


PRACTICAL  TREATISE 


OPEKATIVE  DENTISTRY. 


By   J.    TAFT, 


r-ROFESSOR   OF   OPERATIVE   DENTISTRY   IN   THE   OHIO   COLLEGE   OF 
DENTAL   SURGERY. 


EIGHTY  ILLUSTRATIONS. 


PHILADELPHIA: 

LINDSAY    &    BL  A  K  ISTO  X. 

18  59. 


Entered,  according  to  Act  of  Congress,  in  the  year  1859, 

BY    LINDSAY    &    BLAKISTOX, 

In  the  Clerk's  Office  of  the  District  Court  for  the  Eastern  District  of  Pennsylvania. 


C.  SHERMAN  &  SON,  PRINTERS, 
Corner  Seventh  and  Cherry  Streets,  Philadelphia. 


PREFACE. 


The  exigences  of  the  Profession  seemed  to  require, 
for  the  department  of  Operative  Dentistry,  a  work  that 
should  contain  all  that  is  known  in  this  branch  of 
the  science.  To  answer  that  requirement,  the  author 
of  the  present  work  has  aimed  to  furnish,  in  as  com- 
pact a  form  as  possible,  the  Principles  of  the  Science, 
properly  digested,  the  Experiments  Detailed,  the 
Manipulations  Described,  and  the  whole  methodized 
and  thus  made  available  to  the  Student  and  the 
Practitioner.  In  the  accomplishment  of  this  object, 
he  has,  he  believes,  included  everything  meritorious  or 
important  in  this  department  of  Dental  Study. 

To  the  dental  writers  whose  labors  have  lightened, 
in  any  degree,  the  toil  of  this  undertaking,  the  intelli- 
gent reader  will  ascribe  the  credit  due;  and  to  the 
members  of  the  profession,  whose  suggestions  have 
found  place  in  various  parts  of  the  volume,  the  author 
gratefully  acknowledges  his  obligations. 

J.  TAFT. 

Cincinnati,  July  1,  1859. 


CONTENTS. 


CHAPTER  I. 

PAGE 

Introduction,              ..... 

17 

Deposits,              ...... 

18 

Tartar,    ...... 

18 

Origin  of,           .... 

19 

Points  of  Deposit,  .... 

20 

Effects  of,          ....            . 

21 

Method  of  Removing, 

22 

Green  Tartar,           ..... 

24 

Origin  of,    . 

25 

Treatment  of,  . 

26 

Irregularity,                ..... 

27 

Effects  of,     . 

28 

Atrophy,         ...... 

29 

Cause  of,      . 

39 

Effects  of,           .... 

31 

Exostosis,            ...... 

31 

Effects  of,           .... 

33 

Cause  of,      . 

33 

Denuding,      ...... 

34 

Chemical  Abrasion,          ..... 

36 

Cause  of,             .... 

37 

Necrosis  of  the  Teeth,    ..... 

38 

Causes  of,           .... 

39 

XU  CONTENTS. 

CHAPTER  II. 

PAGE 

Caries  of  the  Teeth,  .......        41 

Causes  of  Caries,     .             .             .            .            .             .  51 

Predisposing  causes  of  Caries,       .            .            .  .51 

Exciting  causes  of  Caries,        ....  55 

Comparative  liability  to  Decay,              .             .             .  .62 

Consequences  of  Caries,      ......  G3 

Treatment  of  Caries,      .             .             .             .             .  .66 

CHAPTER  III. 

General  Remarks  on  Filling,       .             .             .             .             .  71 

Materials  for  Filling,      ......  75 

Lead, 79 

Tin, 80 

Silver, 81 

Platinum,    .......  82 

Gold, 83 

Various  Preparations  of  Gold,  .  .  .85 

Crystal  Gold,          .....  86 

Amalgam,   .......  88 

Nonmetallic  Materials,         .            .             .             .            .  91 

CHAPTER  IV. 

Instruments  for  Filling,         ......         94 

Heavy  Cutting  Instruments,  ....  94 

Drills,     ........        96 

Bur  Drills,         ......  96 

Common  Drills,       .  .  .  .  .  .98 

Drill  Stocks,      .  .  .  .  .  .  100 

Broaches,    .  .  .  .  .  .  .101 

Excavators, .  .  .  .  .  .  .  101 

Manufacture  of  Excavators,  .  .  .  .105 

Plugging  Instruments,         .....  106 


CONTENTS.  XIII 

PAGE 

The  File, .111 

Use  of  the  File,  .  .  .  .  .  113 

Mode  of  using  the  File,       .  .  .  .  .114 

CHAPTER  V. 

Separation  of  the  Teeth,  .  .  .  .  .  118 

CHAPTER  VI. 

Filling  of  Teeth,        .......      124 

Examination,  .  .  .  .  .  .  125 

Opening  Cavities,  .  .  .  .  .  .126 

Removal  of  Decay,  .  .  .  .  .  .  128 

Forming  Cavities,  ......      131 

Drying  Cavities,       .  .  .  .  .  .  139 

Introducing  the  Filling,  .....      142 

Block  Filling, 148 

Forming  Blocks,     ......      149 

Introducing  the  Blocks,  .  .  .  .  151 

Pellets,        .  .  .  .  .  .  .154 

Adhesive  Foil,  ......  154 

Crystal  Gold,      .  .  .  .  .  .  .158 

Finishing  Fillings,  .  .  .  .  .  .  162 

CHAPTER  VII. 

Classification  of  Decayed  Cavities,  .....  166 

Filling  by  Classes  and  Modifications,  .  .  .  168 

First  Class,  ......  168 

Filling  with  Foil,   .....  173 

Adhesive  Foil,  .....  175 

Crystal  Gold, 177 

1st  Modification,  .....  177 

2d  Modification,         .....  179 

Second  Class,  ......  180 

1st  Modification,        .....  181 


XIV  CONTENTS. 

PAGE 

Third  Class, 183 

2d  Modification, 186 

Fourth  Class,  .  .  .  .  .  .187 

1st  Modification,        .  .  .  .  .  191 

2d  Modification,  .  .  .  .  .  .193 

3d  Modification,         .  .  .  .  .  194 

4th  Modification,  .  .  .  .  .195 

Fifth  Class, 197 

Special  Cases,  .  .  .  •  .199 

The  Palatal  portion  of  the  Crown  broken  away, 
leaving  the  outer  portion  standing — nerve  not 
exposed,     .....  200 

Filling  large  Cavities  on  the  Labial  Surfaces  of 

the  Superior  Incisor,    ....      204 

CHAPTER  VIII. 

Pathological  Conditions,  .....  20G 

Treatment  of  Inflamed  Dentine,  .  .  .  .210 

Tannin,  or  Tannic  Acid,      .  .  .  .  .  213 

Creosote,  or  Carbolic  Acid,         .....      214 

Nitrate  of  Silver,      ......  214 

Chlorid  of  Zinc,  .  .  .  .  .  .216 

Terchlorid  of  Gold,  .  .  .  .  .  217 

Arsenious  Acid,  ......      218 

Alkaline  Caustics,    ......  220 

CHAPTER  IX. 

Exposed  Pulps,          .......  221 

Treatment  of  Exposed  Pulps,          ....  223 

Destruction  of  the  Pulp,  .  .  .  .  .231 

Actual  Cautery,             .....  236 

Potential  Cautery,  ......  237 

Arsenious  Acid,            .....  237 

Application  of,             ....  239 


CONTENTS. 


XV 


Filling  Pulp-Cavities  and  Canals, 
Preparing  the  Teeth  for  Filling, 
Alveolar  Abscess,     . 
Treatment  of, 


PAGE 

244 
251 
259 
261 


CHAPTER  X. 


Pivot  Teeth, 

Fitting  the  Crown, 
Attachment  of  the  Crown,  . 
Metallic  Pivots,  . 


268 
272 
275 
279 


CHAPTER  XI. 

Extraction  of  Teeth, 
General  Remarks, 
Indications  for  Extraction,  . 
Extracting  Instruments, 

The  Key, 

Modus  Operandi, 

The  Forceps,    . 

Elevators,    . 

Hooks,  . 

The  Screw, 

The  Gum-Lancet, 
Method  of  Lancing  the  Gums, 
Extraction  of  the  Teeth, 

Superior  Incisors,    . 

Superior  Cuspids, 

Superior  Bicuspids, 

Superior  Molars, 

Extraction  of  Roots, 

Removal  of  the  Dentes  Sapiential, 

Extraction  of  the  Inferior  Incisors, 
Roots, 

Inferior  Cuspids,     . 

Inferior  Bicuspids, 


285 
285 
292 
294 
295 
296 
299 
311 
312 
313 
315 
317 
319 
319 
321 
323 
326 
327 
329 
331 
332 
332 
334 


XVI  CONTENTS. 

PAGE 

Inferior  Molars,       ......  335 

Inferior  Dentes  Sapiential,        ....  339 

Extraction  preparatory  to  the  Insertion  of  Artificial  Den- 
tures, ......  340 

Conditions  to  be  observed  in  the  Extraction,  .  .  342 

CHAPTER  XII. 

Accidents  in  the  Extraction  of  Teeth,    .'  347 
Hemorrhage,      .......      348 

Treatment,        ......  350 

Fracture  of  the  Alveolus,           .             .             .             .  .358 

Laceration  of  the  Gums,      .....  360 

Breaking  the  Teeth,       .             .             .             .             .  .361 

Removal  of  a  Wrong  Tooth,            ....  362 

Dislocation  of  the  Inferior  Maxillary,    .             .             .  .363 

Syncope,       .......  365 

CHAPTER  XIII. 

Anesthetics,   ........  368 

Ether— Chloroform,  .....  368 

Local  Anesthesia,  ......  372 

Congelation,      ......  373 

Extraction  by  Electro-Magnetism,         ....  375 

Application,      ......  377 


OPERATIVE    DENTISTRY. 


CHAPTER  I. 

INTRODUCTION. 

As  introductory  to  the  following  treatise,  a  cursory 
consideration  of  those  conditions  and  diseases  of  the 
teeth  which  demand  the  aid  of  dental  surgery,  would 
seem  appropriate.  To  refer,  however,  to  all  of  these, 
or  to  remark  extendedly  upon  any  of  them,  would 
not  be  consistent  with  the  design  of  this  work,  or 
necessary  to  a  proper  understanding  of  the  subjects 
proposed.  Only  those  affections  which  pertain  to  the 
teeth  directly,  and  which,  for  the  most  part,  are  con- 
fined to  the  tooth-substance  itself,  will  here  require 
attention.  Nor  will  the  pathology  of  contiguous 
parts  be  introduced ;  for  the  appropriate  treatment  of 
these,  being  mainly  therapeutic  rather  than  surgical, 
would  involve  a  discusssion  of  questions  not  within 
the  scope  of  the  present  volume.     Indeed,  it  is  pro- 


18  INTRODUCTION. 

posed  merely  to  speak  of  those  affections  of  the  teeth, 
which  general^  suggest  surgical  remedies,  and  which 
are  implicated  more  or  less  in  the  operations  de- 
scribed in  the  following  pages ;  and  first,  of 

DEPOSITS. 

In  this  term  are  included  those  calcareous  forma- 
tions commonly  called  tartar,  a  certain  coloring  mat- 
ter denominated  green  stain,  and  such  other  impuri- 
ties on  the  teeth  as  result  from  neglect,  the  use  of 
tobacco,  and  like  causes.     The  word 

TARTAR 

Implies  all  calcareous  deposits  upon  the  teeth.  Of 
this  substance  there  are  several  varieties,  the  more 
obvious  of  which  have  respect  to  color  and  consist- 
ence. In  color,  there  are  all  shades,  from  a  white  as 
light  as  that  of  the  tooth,  or  even  lighter,  to  a  jet 
black  ;  and  in  consistence,  all  degrees,  from  a  thick, 
gummy  mucus,  to  the  density  of  the  dentine  itself. 
The  color  will,  in  most  cases,  be  indicative  of  the 
density,  the  lightest  shade  corresponding  with  the 
softest,  and  the  darkest  with  the  hardest  consistence. 
The  tenacity  to  the  teeth  is  also  in  proportion  to  the 
density,  the  dense  and  dark  adhering  most  firmly. 
The  density  of  the  deposit,  too,  is  generally  indicative 


TARTAR.  19 

of  the  rapidity  of  its  formation,  being  in  an  inverse 
ratio  to  this. 

All  the  varieties  of  tartar  are  composed  princi- 
pally of  the  same  elements, —  phosphate  of  lime, 
fibrin,  fat,  and  animal  matter  being  contained  in 
them  all,  though  in  various  proportions.  The  fact 
that  some  varieties  are  soluble  in  acids,  and  others 
not,  has  been  adduced  to  prove  that  they  are  en- 
tirely different  in  their  composition.  This,  however, 
is  accounted  for  on  an  other  hypothesis :  in  the  softer 
varieties,  the  phosphate  of  lime  is  so  protected  by 
the  fat  and  the  animal  matter  that,  under  ordinary 
circumstances,  acid  can  not  come  in  contact  with  it; 
but  the  dense  varieties  are  very  soluble,  because  the 
acid  readily  comes  in  contact  with  the  calcareous 
portion. 

Its  origin. — It  is  a  precipitate  of  the  saliva, — or 
at  least  the  phosphate  of  lime,  and  probably  the 
fibrin,  comes  into  the  mouth  with  the  saliva ;  while 
perhaps  the  fat  and  other  animal  matter  are  depo- 
sited from  the  mucus.  In  all  cases  in  which  this 
substance  is  formed  upon  the  teeth,  the  saliva  has  a 
very  definite  alkaline  character,  holding  in  solution 
the  phosphate  of  lime,  which,  by  the  action  of  the 
acid  mucus  upon  the  saliva,  is  precipitated. 

Persons  of  a  lymphatic  temperament,  or  a  ten- 
dency toward  it,  with  muscles  of  a  soft,  flabby  text- 
ure,  hair   light,   teeth  of  a  rather  inferior  quality, 


20  INTRODUCTION. 

and  a  free  flow  of  saliva,  are  most  subject  to  the  de- 
position of  tartar ;  yet  there  are  conditions  of  almost 
all  constitutions,  in  which  it  is  freely  eliminated. 
That  it  is  precipitated  from  the  saliva,  is  a  fact  so 
easily  demonstrated  and  so  generally  admitted,  that 
it  need  not  here  be  considered. 

Points  of  Deposit. — The  points  at  which  it  is  depo- 
sited in  the  greatest  quantities  upon  the  teeth,  are  in 
the  vicinity  of  the  orifices  of  the  salivary  ducts;  and 
hence  it  is  found  most  abundant  on  the  inner  portions 
of  the  inferior  anterior  teeth,  and  on  the  buccal  sur- 
faces of  the  superior  molars.  Frequently,  also,  it 
collects  in  considerable  quantities  upon  the  external 
surfaces  of  the  inferior  front  teeth.  The  points  upon 
the  teeth  to  which  it  most  readily  attaches,  are  at 
the  necks,  immediately  beneath  the  free  margin  of 
the  gum,  and  at  the  termination  of  the  enamel.  A 
nucleus  once  formed,  and  it  encroaches  upon  the 
crown  of  the  tooth,  if  no  means  are  employed  to  pre- 
vent its  lodgment,  at  a  rate  determined  by  the  con- 
dition of  the  saliva. 

It  is  deposited  first  and  most  abundantly  on  the 
necks  of  the  teeth,  because  here  the  saliva  first  comes 
in  contact  with  these  organs,  and  here  remains  for 
the  longest  periods  and  in  the  largest  quantities. 
That  it  is  precipitated  very  soon  after  the  saliva 
enters  the  mouth,  is  evident  from  the  fact  that  it  is 
found  collected  upon  the  superior  molars,  just  in  the 


TARTAR.  21 

vicinity  of  the  orifices  of  the  clucts-of-Wharton,  where 
the  saliva  cannot  he  retained  for  any  considerahle 
time,  by  reason  of  the  position,  but  must  very  soon 
pass  along  upon  the  surfaces  of  the  contiguous  teeth, 
on  which  we  generally  find  it  deposited  in  much 
smaller  quantities.  Indeed,  this  calcareous  deposi- 
tion has  been  sometimes  found  in  the  salivary  ducts 
themselves. 

Its  Effects. — It  exercises  no  directly  injurious  influ- 
ence upon  the  substance  of  the  teeth ;  but  it  is  highly 
prejudicial  to  the  parts  immediately  in  connection 
with  them,  upon  which  they  depend  for  support.  It 
encroaches  upon  the  gums  and  alveoli,  and  causes  an 
absorption  of  these  important  surroundings ;  and  as 
they  become  absorbed,  its  encroachments  are  accele- 
rated. In  some  constitutions  this  process  goes  on 
with  little  or  no  annoyance  to  the  patient;  while  in 
others,  irritation,  inflammation,  and  even  suppuration 
of  the  gums  occur;  and  thus  their  destruction  is  effected 
in  a  twofold  manner.  This  irritation  and  inflamma- 
tion may  extend  to  the  mucous  membrane,  and  in- 
volve all  the  adjacent  parts.  The  dental  periosteum, 
also,  if  susceptible,  as  in  many  cases  it  is,  will  become 
implicated  in  the  difficulty;  periostitis  will  ensue, 
and  often  suppuration,  thus  breaking  up  the  attach- 
ments of  the  teeth  even  before  the  surroundings  are 
removed.  The  alveolus,  too,  becomes  diseased,  and 
in   some  instances  its  death  and   exfoliation  result. 


22  INTRODUCTION. 

Salivary  calculus,  however,  never  induces  caries  of 
the  teeth,  nor  even  favors  it.  On  the  contrary,  we 
frequently  meet  with  instances  of  decay  entirely  ar- 
rested by  a  deposit  of  tartar  in  the  cavity. 

Persons  of  all  ages  are  subject  to  this  affection ; 
those  past  middle  life  being  most  so,  and  those 
advanced  in  years  sometimes  having  teeth  nearly 
covered  with  tartar.  There  are  some  constitutions 
whose  diathesis  is  favorable  to  a  deposition  of  sali- 
vary calculus  through  life.  Others,  again,  will  be 
perfectly  exempt  from  it  till  some  peculiar  constitu- 
tional change  intervenes,  when  it  will  begin  to  be 
rapidly  eliminated. 

Method  of  removing  It. — The  removal  of  salivary 
calculus  is  an  operation  that  does  not  involve  a  great 
amount  of  skill,  but,  with  suitable  appliances,  is 
easily  performed.  There  are  two  methods  of  effect- 
ing it ;  the  one,  that  of  scaling  and  scraping,  and  the 
other,  that  of  decomposing  the  deposit  by  the  appli- 
cation of  an  acid.  The  former  is  always  to  be  pre- 
ferred ;  for,  in  the  latter,  the  chemical  action  of  the 
acid  does  not  stop  with  a  decomposition  of  the  de- 
posit, but,  by  the  same  affinity,  attacks  the  tooth 
itself.  For  the  successful  accomplishment  of  the 
operation,  instruments  of  various  forms  and  curves 
will  be  necessary,  adapted  and  adjusted  to  the 
various  shapes  and  situations  of  the  surfaces  to  be 
operated  upon.     The  most  common  forms  are  repre- 


TARTAR. 


9?, 


sen  ted  in  the  following  figure.  The  blade  of  the  in- 
strument should  be  applied  at  a  slightly  obtuse  angle 
with  the  surface  of  the  tooth,  just  beyond  the  edge  of 


Fiff.  1. 


the  deposit  next  the  gum,  and  thus  slid  under  the 
tartar,  scaling  it  off  to  the  point,  in  such  a  manner 
as  not  to  roughen  up  or  abrade  the  enamel.  Deposits 
of  this  substance  on  proximal  surfaces  of  the  teeth 
are  to  be  carefully  observed,  and  removed  with  in- 
struments of  attenuated  blades.  When  the  thick 
incrustations  have  been  thus  removed,  the  surface 
should  then  be  gently  scraped,  so  as  entirely  to  clean 
off  all  remaining  portions,  and  afterward  thoroughly 
polished  with  fine  pumice,  or  Arkansas-  or  rotten-stone, 
and  finished  by  burnishing.  During  the  operation,  a 
frequent  employment  of  the  toothbrush  with  water 
will  be  required,  to  cleanse  the  mouth  of  the  detached 
deposits  and  the  increased  secretions;  and,  in  general, 
the  completion  of  the  process  will  occupy  more  than 
one  sitting.     Since  this  deposit  often  extends  beneath 


24  INTRODUCTION. 

the  free  margin  of  the  gum,  much  care  is  necessary 
to  see  that  it  all  be  removed. 


GREEN    TARTAR. 

This  deposit  has  been  so  referred  to  by  writers,  as 
to  convey  the  impression  that  it  is  of  the  same 
generic  character  as  salivary  calculus.  Such  a  mis- 
apprehension is  hardly  pardonable.  The  teeth  of 
young  persons  only  are  subject  to  this  affection,  it 
being  often  found  on  those  of  children  three  or  four 
years  old.  It  almost  always  appears  on  the  labial 
surfaces  of  the  superior  front  teeth,  and  in  largest 
quantity  near  the  margin  of  the  gum.  It  is  seldom 
seen  on  the  inferior  teeth,  and  only  on  the  anterior 
surfaces  of  the  superior.  The  color  of  this  deposit  is 
very  dark,  inclining  to  green.  Wherever  it  attaches, 
the  surfaces  of  the  teeth  are  abraded,  and  when  it  is 
of  long  standing,  the  entire  enamel  beneath  it  is 
destroyed,  and  the  dentine  is  gradually  involved  in 
the  dissolution.  This  effect  upon  the  teeth  is  not 
produced  by  the  coloring  matter  observed  upon  them, 
but  by  an  acid  in  combination  with  this  material 
before  it  is  deposited.  The  stain  is  a  precipitate 
from  this  compound,  and  the  acid,  leaving  this,  com- 
bines with  the  calcareous  ingredients  of  the  teeth, 
to  their  detriment  as  above;  but  the  precipitate  is 
entirely  innocent. 


GREEN   TARTAR.  25 

Its  Origin. — Green  tartar,  or  green  stain,  doubtless 
lias  its  origin  in  the  mucus,  when  this  is  in  a  particular 
acid  condition.  That  it  does  not  proceed  from  the 
saliva  is  proved  by  the  fact  that  it  is  never  found 
where  there  is  a  free  flow  of  saliva,  or  where  this  has 
free  access;  but  the  point  of  its  deposit  is  where  the 
saliva  is  least  frequently  present,  being  most  abun- 
dant in  cases  in  which  there  is  a  large  relative 
amount  of  mucus,  and  this  in  a  very  acid  condition. 
But  the  query  might  arise  here,  if  the  mucus  of  the 
mouth  were  wholly  in  that  condition,  why  would  not 
the  teeth  suffer  from  it  elsewhere.  Because,  on  the 
masticating  surfaces  of  the  teeth,  the  friction  of  the 
food  will  prevent  it,  and  on  the  inner  surfaces,  the 
friction  of  the  ton  sue ;  besides,  wherever  there  is  a 
free  flow  of  saliva,  this  will  have  a  counteracting 
effect.  Decay  goes  on  very  rapidly,  after  it  has  once 
commenced,  upon  teeth  affected  by  this  deposit. 

There  are  points  of  dissimilarity  between  this  green 
tartar  or  stain  and  salivary  calculus,  that  it  may  be 
well  to  notice.  The  latter  is  from  the  saliva ;  the 
former  from  the  mucus ;  and  hence  the  one  exists 
where  there  is  an  abundant  flow  of  saliva,  and  the 
other  where  the  relative  quantity  of  this  is  small. 
The  calculus  is  deposited  when  the  saliva  is  in  an 
alkaline  condition  ;  the  stain,  when  the  mucus  is 
very  acid.  The  former  is  deposited  in  large  quanti- 
ties and  thick  incrustations,  and  upon  the  surfaces  of 


26  INTRODUCTION. 

the  teeth,  and  is  easily  removed  without  detriment 
to  their  substance ;  whereas  the  latter  is  a  thin  film, 
barely  sufficient  to  stain  the  surface,  and  yet  it  enters 
into  the  tooth-substance  itself,  and  cannot  be  removed 
without  detaching  some  portion  of  the  tooth  with  it. 
The  one  seems  rather  preventive  of  caries,  which 
does  not  occur  beneath  it ;  but  the  other  is  highly 
promotive  of  decay.  With  these  marked  features 
of  difference,  it  is  surprising  that  the  two  should 
ever  have  been  confounded,  since  it  is  so  important 
that  the  distinctive  character  of  each  be  understood, 
in  order  to  its  correct  treatment. 

Treatment. — In  order  to  a  perfect  and  final  remedy 
for  green  stain,  therapeutic  treatment  must  be  com- 
bined with  the  operative ;  but  only  the  latter  will  be 
here  described,  which  has  for  its  object  the  removal 
of  the  deposit,  and  the  rendering  of  the  eroded  sur- 
face smooth  and  polished.  There  are  two  or  three 
methods  of  accomplishing  this  object.  When  the 
erosion  is  but  slight,  it  will  be  effected  with  pul- 
verized pumice  or  Arkansas-stone,  applied  with  water 
till  the  stain  disappears,  and  with  the  subsequent  use 
of  the  burnisher  with  a  solution  of  soap.  But  when 
the  erosion  is  too  extensive  to  be  thus  reduced,  it 
must  be  cut  down  with  a  file,  and  then  finished  with 
stone  and  burnisher,  as  before.  And  when  the  ero- 
sion is  extreme,  a  cutting-instrument  must  precede 
the  file. 


IRREGULARITY.  27 


IRREGULARITY. 


By  this  term  we  imply  those  variations  from  a 
beautiful  and  natural  position,  in  which  the  teeth  are 
so  frequently  found.  The  principal  cause  of  irregu- 
larity is  a  disproportion  between  the  actual  size  of 
the  arch,  and  the  size  required  for  the  accommoda- 
tion of  the  teeth.  When  this  disproportion  exists, 
the  teeth  which  are  first  irrupted,  occupy  very  nearly 
their  proper  position ;  but  those  which  come  in  after- 
ward, are  more  or  less  disarranged,  in  proportion  to 
the  preoccupation  of  the  space.  There  are  cases  in 
which  the  roots  of  the  temporary  teeth  are  not  ab- 
sorbed, and  the  permanent  teeth  are  irrupted  out  of 
their  true  position,  even  when  there  is  room  enough 
for  them  were  the  former  removed.  Irregularity  is 
mainly  confined  to  the  front  teeth,  and  consists  in 
either  an  inward  or  an  outward  inclination,  and,  in 
some  instances,  both.  Sometimes  the  incisors  are 
turned  round  in  the  socket,  so  that  the  edge  stands  at 
a  very  considerable  angle  with  the  proper  position. 

The  upper  teeth  are  oftener  materially  disarranged 
than  the  lower,  though  the  latter  frequently  exhibit 
some  irregularity  in  front,  in  consequence  of  a 
crowded  condition.  The  teeth  most  liable  to  be  out 
of  position  are  the  cuspidate.  These,  of  the  teeth  of 
replacement,  are  the  last  in  their  irruption ;  and  it 
often  occurs  that  the  arch  is  previously  wellnigh  oc- 


28  INTRODUCTION. 

cupied ;  in  which  case  they  are  thrown  outward. 
When  there  is  any  irregularity  of  the  bicuspids,  it  is 
that  of  an  inward  inclination.  The  first  and  second 
molars  are  very  seldom  out  of  proper  position.  The 
third  molars,  however,  for  wrant  of  room,  are  some- 
times thrown  out  toward  the  cheek,  or  even  pre- 
vented from  coming  out  at  all  in  any  direction. 

Effects. — In  all  cases,  irregularity  is  favorable  to 
decay.  It  is  even  maintained  by  some  that  the 
organic  structure  of  irregular  teeth  is  less  perfect 
than  that  of  regular,  because  the  former  are  impeded 
in  their  irruption,  and  thus  impaired.  But  this,  to 
say  the  least,  is  questionable ;  for  it  will  be  remem- 
bered that  the  crowns  of  the  teeth  are  formed  and 
completely  ossified  before  they  can  be  affected  by  a 
crowded  state ;  and  it  is  hardly  probable  that  they 
could  be  materially  modified  in  their  structure  after 
this  period.  The  crowns  of  the  teeth  are  never  de- 
formed by  a  crowded  condition.  The  principal  cause 
of  the  liability  of  irregular  teeth  to  decay,  is  the  fa- 
cility they  furnish  for  the  lodgment  of  foreign  sub- 
stances about  them,  and  the  difficulty  they  present  to 
its  removal.  And  again,  in  irregular  teeth,  parts  are 
approximated  that  nature  did  not  intend  should  be 
brought  together.  Irregularity  impairs  the  speech, 
impedes  the  mastication,  and  often  distorts  the  coun- 
tenance and  deforms  the  features. 


ATROPHY.  29 


ATROPHY, 


This  affection  is  characterized  by  defective  spots  in 
the  enamel,  white,  chalklike — which  scarcely  ever 
penetrate  the  dentine.  In  these  spots  there  is 
nothing  of  that  organic  structure  exhibited  by  well 
formed  enamel.  They  are  in  all  cases  quite  small, 
but  vary  greatly  in  number.  They  are  often  found 
arranged  in  transverse  rows  across  the  tooth  affected. 
The  superior  incisors  are  most  frequently  found  with 
atrophy,  though  the  bicuspids  and  molars  sometimes 
exhibit  it.  The  front  upper  teeth  are  attacked  by  it 
only  on  the  anterior  surfaces. 

Instead  of  the  spots,  we  sometimes  find  pits,  or 
indentations,  into  or  through  the  enamel,  which  occa- 
sionally run  together,  so  as  ultimately  to  form  trans- 
verse grooves  of  considerable  extent  upon  the  teeth. 
In  many  cases,  where  on  the  irruption  of  the  teeth 
the  spots  only  are  presented,  the  organs  are  not 
injured,  except  in  appearance,  the  spots  retaining 
the  smooth,  enamellike  surface  during  life.  In  other 
cases,  the  spot  is  of  such  a  soft,  friable  texture,  that 
it  early  crumbles  out,  leaving  the  little  pits  above 
referred  to.  These  indentations,  however,  sometimes 
exist  at  the  first  appearance  of  the  tooth,  but  more 
frequently  afterward,  being  formed  by  the  crumbling- 
away  of  the  defective  portion. 

Atrophy  usually  occurs  on  teeth  of  good  structure, 


30  INTRODUCTION. 

short,  thick  crowns,  and  rather  yellowish  color.  The 
long,  thin,  white  tooth,  of  imperfect  organization  and 
insufficient  density,  seldom  or  never  presents  an  atro- 
phied condition. 

The  Cause. — It  may  be  difficult  to  point  out  the 
precise  cause  of  this  affection,  but  some  facts  in  re- 
gard to  it  are  very  obvious.  There  is,  in  every  case, 
an  obstruction  in  the  development  of  the  enamel  at 
the  point  of  defect,  and  at  the  time  of  its  origination. 
In  some  cases,  doubtless,  there  are  a  deficient  amount 
and  an  inferior  quality  of  the  material  elaborated  for 
the  upbuilding  of  the  structure;  and  this  is  probably 
the  case  when  the  pits  exist  at  the  irruption  of  the 
teeth.  In  other  instances,  the  requisite  quantity  of 
material  may  be  elaborated,  and  yet  the  vital  energy 
be  insufficient  to  organize  it,  as  in  the  case  of  the 
spots  referred  to.  The  latter  condition  is  more  fre- 
quent than  the  former,  as  is  evidenced  by  the  more 
frequent  appearance  of  the  spots  than  of  the  pits. 
We  are  led  to  infer,  then,  that  the  origin  of  this 
affection  is  for  the  most  part  constitutional,  and  not 
local.  There  are  commonly  found  traces  of  it  on  all 
the  teeth  whose  enamel  was  in  process  of  formation 
at  the  time  of  the  interruption. 

Any  general  disturbance,  such  as  to  interrupt  the 
assimilative  process,  would  be  detrimental  to  the  per- 
fect formation  of  the  tooth.  Again,  some  affections 
may  materially  affect  the  organizing   power  of  the 


EXOSTOSIS.  31 

system,  without  interfering  with  the  assimilative 
power.  Any  disease  that  should  interrupt  the  func- 
tions of  the  digestive  apparatus,  would  be  prejudicial 
to  the  process  of  assimilation  ;  whilst  other  diseases, 
such,  for  instance,  as  those  of  a  febrile  character, 
would  diminish  the  vital  power,  and  consequently 
the  ability  to  build  up  organic  structures,  without 
interrupting  in  any  special  manner  the  process  of 
assimilation.  These  things  are  referred  to  here  for 
the  purpose  of  showing  under  what  circumstances 
atrophy  of  the  teeth  may  occur. 

Effects. — In  the  best  formed  teeth,  there  are  no 
unpleasant  results  from  atrophy,  other  than  its  de- 
traction from  their  beauty.  The  spots  are  unsightly, 
and  when  the  pits  are  present,  they  become  dark, 
and  sometimes  black,  from  deposit ;  which,  by  ordi- 
nary means,  is  difficult  of  removal.  In  teeth  of  infe- 
rior structure,  decay  often  supervenes  in  these  pits, 
and,  extending  thence,  involves  the  other  parts ;  and 
anything  that  will  affect  the  tooth-substance,  will 
affect  the  spots  in  a  greater  degree. 

EXOSTOSIS. 

This  term,  critically  denned,  implies  outgrowth  from 
a  bone;  but,  as  applied  to  the  bones  generally,  and 
particularly  to  the  teeth,  it  probably  conveys  the  idea 
of  groicth  upon  a  bone.     The  affection  thus  clenomi- 


32  INTRODUCTION. 

nated  is  common  to  all  the  bones ;  some,  however, 
being  more  frequently  attacked  by  it  than  others. 
It  occurs  upon  the  roots  of  the  teeth,  but  is  never 
developed  where  there  is  no  periosteum.  The  man- 
ner of  its  deposit  is  not  uniform  ;  but  it  is  commonly 
in  an  enlargement  on  the  point  of  the  root,  or  from 
the  point  some  distance  toward,  and  occasionally  all 
the  way  to,  the  neck  of  the  tooth.  In  some  cases,  it 
extends  entirely  round  the  root,  and  in  others,  is  con- 
fined to  one  side.  It  sometimes  results  in  such  an 
enlargement  of  the  root,  especially  if  it  is  near  the 
point,  as  to  render  the  tooth  very  difficult  of  removal. 
When  it  is  bulb-form,  the  entire  attachment  of  the 
tooth  may  be  broken  up,  so  as  to  allow  this  to  rotate 
in  the  socket,  and  yet  the  tooth  be  very  difficult  to 
remove ;  indeed,  in  some  instances,  impossible,  with- 
out cutting  away  a  portion  of  the  process. 

The  density  of  the  deposit  is  usually  greater  than 
that  of  the  root  on  which  it  is  found ;  though  in  this 
respect  there  is  considerable  variation  :  in  a  few  in- 
stances wre  have  found  it  softer  than  the  root  proper. 
The  surrounding  parts  are  absorbed  for  its  accommo- 
dation. The  color  of  the  substance  is  slightly  yellow, 
not  differing  much  from  that  of  the  root  itself;  and 
frequently  it  exhibits  a  seinitranslucent  appearance. 
The  rate  of  its  formation  varies  considerably,  some- 
times increasing  so  rapidly  as  to  occasion  much  diffi- 
culty, and  at  other  times  seeming  to  advance  very 


EXOSTOSIS.  33 

slowly ;  and  frequently  it  is  arrested  altogether. 
Roots  are  often  found  affected  with  exostosis,  that 
have  been  dead  and  crownless  for  a  number  of  years, 
and  yet  have  never,  so  far  as  known,  given  any  trouble 
because  of  the  affection ;  and  teeth  perfectly  healthy 
in  other  respects  may  be  thus  affected. 

Its  Effects. — It  always  increases  the  difficulty  of  re- 
moving the  tooth,  either  by  enlargement  of  the  point 
of  the  fang,  or  by  deposit  upon  one  side  of  it,  causing 
it  to  curve ;  in  which  latter  case  the  difficulty  is  all 
the  greater,  from  the  impossibility  of  determining  the 
direction  of  the  curve.  It  sometimes  produces  a  dis- 
eased condition  of  the  surrounding  parts — in  some  in- 
stances chronic  inflammation — that  will  continue  as 
long  as  the  tooth  remains.  Nervous  affections  often 
result  from  exostosis,  either  through  irritation  caused 
by  pressure  on  the  nerve,  or  through  the  diseased 
condition  of  the  surrounding  parts.  The  floor  of  the 
antrum  is  sometimes  absorbed  away,  in  consequence 
of  the  enlargement  of  the  point  of  the  fang;  and 
•then  disease  of  the  lining  membrane  of  that  cavity 
generally  ensues. 

The  Cause. — The  cause  of  this  affection  is  not  well 
understood.  It  is  most  probably  deposited  by  the 
periosteum  when  this  is  in  an  abnormal  condition  ;  but 
what  peculiar  condition,  it  is  not  clearly  ascertained, 
though  some  have  supposed  it  to  be  inflammation. 
It  is  patent,  however,  that  something  more  than  a 


34  INTRODUCTION. 

state  of  simple  inflammation  exists ;  for  there  is  in- 
flammation in  numerous  instances  without  this  de- 
posit. Again,  in  all  cases  where  there  is  periostitis, 
that  state  is  definitely  indicated  by  percussion  upon 
the  affected  tooth ;  indeed,  in  the  occlusion  of  the 
jaws,  pain  is  usually  experienced.  Yet  there  are 
found  many  teeth  whose  roots  are  subjects  of  this 
deposit,  that  have  never  given  any  indications,  either 
by  pain  or  otherwise,  of  a  diseased  condition. 

This  subject  is  one  in  which  there  is  room,  at  least 
so  far  as  dentists  are  concerned,  for  extensive  obser- 
vation. 


DENUDING. 

This  consists  in  a  wasting-away  of  the  enamel  of 
the  anterior  teeth,  from  the  points  toward  the  necks. 
The  affection,  however,  is  of  too  rare  occurrence  to 
demand  extended  consideration.  The  color  of  the 
enamel  is  not  changed  by  this  process,  nor  is  its 
natural  polish  impaired  by  any  abrasion.  The  den- 
tine, on  becoming  exposed  by  this  removal  of  its 
natural  protection  or  covering,  is  perfectly  smooth, 
but  of  a  yellowish  cast,  in  some  cases  inclining  to 
brown.  When  the  enamel  is  removed,  there  seems 
to  be  a  cessation  of  the  destructive  process ;  for  the 
crowns  of  such  teeth  will,  in  many  instances,  endure 


DENUDING.  35 

for  a  long  time — indeed,  till  they  are  worn  down  by 
the  friction  in  mastication. 

This  wasting  process  usually  begins  at  the  points 
of  the  teeth,  and  proceeds  toward  the  necks,  on  all 
sides,  till  the  enamel  is  entirely  destroyed.  Some- 
times, however,  it  commences  on  their  labial  sur- 
faces ;  this  is  particularly  the  case  with  the  superior 
anterior,  but  very  seldom  with  the  inferior  teeth. 
The  affection,  however,  attacks  the  inferior  more  fre- 
quently than  the  superior  teeth ;  yet  it  is  often  found 
assailing  both  with  about  equal  energy. 

The  cause  of  the  disease  is  not  well  understood, 
though  it  is  generally  conceded  to  be  the  operation 
of  an  acid  contained  in  the  mucus.  Doubtless,  the 
agent  producing  the  affection  is  contained  in  the 
mucus ;  for  it  usually  occurs  where  there  is  a  large 
relative  amount  of  this  secretion ;  but  that  it  is  an 
agent  of  a  very  decided  acid  character,  we  are  not 
prepared  to  affirm.  Decay  of  the  teeth  does  not  seem 
to  progress  with  greater  rapidity  while  this  affection 
exists,  than  at  other  times;  and  again,  the  enamel 
does  not  present  the  roughened,  abraded  appearance 
we  find  resulting  from  the  operation  of  any  ordinary 
agent.  With  these  apparently  incongruous  facts,  it 
is  rather  difficult  to  arrive  at  a  definite  conclusion  as 
to  the  precise  manner  in  which  this  condition  is  pro- 
duced, or  the  exact  character  of  the  agent  instru- 
mental in  its  production. 


36  INTRODUCTION. 


CHEMICAL    ABRASION. 


This  consists  in  a  gradual  destruction  of  the  entire 
substance  of  the  crown  of  the  tooth — the  enamel  and 
the  dentine.  It  is  an  affection  of  comparatively  rare 
occurrence.  It  assails  the  superior  more  often  than 
the  inferior  teeth,  though  both  are  subject  to  it.  It 
begins  upon  the  points  of  the  central  incisors,  wast- 
ing them  away  most  rapidly  at  the  median  line,  from 
which  it  progresses  each  way,  involving  the  lateral 
incisors,  cuspids,  and  sometimes  the  bicuspids,  so  that 
a  curved  line  is  presented  by  the  edges  of  the  teeth, 
of  greater  or  less  inclination,  according  to  the  rapidity 
of  the  process.  When  the  superior  teeth  only  are 
affected,  the  opening  between  the  ends  of  the  upper 
and  of  the  lower  front  teeth,  when  closed,  is  a  semi- 
ellipsis.  If  the  inferior  teeth  are  affected,  as  is  some- 
times the  case,  then  the  opening  will  be  an  ellipsis. 

In  the  case  of  Mr.  G.,  the  affection  had  been  in 
process  about  two  years  and  a  half;  the  wasting- 
away  extended  to  the  first  bicuspids  both  above  and 
below;  and  when  the  jaws  were  closed,  the  ends  of 
the  upper  and  of  the  lower  central  teeth  were  about 
one  third  of  an  inch  asunder,  and  the  opening  was  of 
the  elliptical  form.  It  was  a  mystery  to  him.  Twto 
years  and  a  half  before,  his  anterior  teeth  shut  close 
together  on  the  ends.  He  had  not  used  them  in  the 
mastication  of  his  food,  for  his  molar  teeth  were  all 


CHEMICAL    ABRASION.  37 

good,  and  sufficient  for  this  purpose ;  and  moreover  it 
had  been  impossible  for  him  to  use  them  in  mastica- 
tion, since  he  could  not  bring  them  together ;  and  he 
had  not  been  in  the  habit  of  putting  any  hard  sub- 
stance between  them. 

The  Cause. — The  cause  of  this  affection,  like  that 
of  denuding,  is  not  well  understood.  It  is  supposed, 
however,  to  be  induced  by  an  acid  contained  in  the 
mucus.  If  this  supposition  is  correct,  it  must  be 
some  acid  with  whose  nature  we  are  but  little,  if  at 
all,  acquainted ;  or,  if  any  ordinary  acid,  it  certainly 
must  be  modified  by  very  peculiar  circumstances. 
The  surface  upon  which  it  acts  is  always  perfectly 
smooth  and  polished,  never  presenting  that  rough- 
ened and  abraded  appearance  caused  by  the  action  of 
any  ordinary  acid  upon  enamel  or  dentine.  And 
again,  if  this  affection  results  from  the  operation  of 
an  acid  in  the  mucus,  why  does  not  this  acid,  to 
some  extent  at  least,  affect  the  teeth  at  other  points  ? 
Such  is  not  the  fact;  and  caries  that  has  previously 
commenced  at  other  points  on  the  teeth,  does  not 
progress  more  rapidly  during  the  existence  of  this 
disease,  than  before ;  but  it  certainly  would,  if  there 
were  a  large  quantity  of  acid  in  the  mucus. 

It  has  been  supposed  that  the  mucous  follicles  of 
that  part  of  the  tongue  which  comes  in  contact  with 
the  teeth  at  the  affected  part,  are  the  agents  that 
produce  the  disease.     Of  this,  however,  there  is  not 


38  INTRODUCTION. 

evidence  sufficient  to  warrant  an  adoption  ot  the 
theory.  The  cupping  of  the  molars  and  cuspids 
bears  strong  indications  of  being  an  analogous  pro- 
cess, and  yet  no  such  influence  can  exist  for  its  ac- 
complishment. We  have  no  theory  on  this  subject 
to  present,  regarding  it  as  still  an  open  field  for  in- 
vestigation. There  can  be  little  doubt,  however,  that 
the  cause  of  denuding,  of  chemical  abrasion,  and  of 
cupping,  has  its  origin  in  the  constitution,  is  not 
merely  local,  and  may  be  removed,  and  the  affection 
arrested,  by  constitutional  treatment. 

NECROSIS    OF    THE    TEETH. 

By  this  term  is  understood  the  death  of  the  part 
affected.  It  has  been  remarked  that  the  condition  is 
similar  to  mortification  in  the  soft  parts  of  the  sys- 
tem. But  in  the  latter  there  occurs  a  change  of 
structure ;  whereas,  in  the  bones,  and  particularly  in 
the  teeth,  there  is  not  necessarily  any  change  conse- 
quent on  the  loss  of  vitality.  The  teeth  have  their 
organic  connection  with  the  surrounding  parts  by  the 
external  and  the  internal  periosteum  and  the  pulp ; 
their  crowns  depend  for  vitality  upon  the  internal 
organism ;  and  when  this  is  destroyed,  they  are 
wholly  necrosed,  or  deprived  of  vitality,  as  is  evident 
from  the  total  loss  of  sensibility  in  them  immediately 
after  the  destruction  of  the  pulp. 


NECROSIS    OF   THE    TEETH.  39 

Necrosis  of  the  teeth  differs  from  that  of  the  other 
bones  in  some  particulars,  one  of  the  most  obvious  of 
which  is,  that  in  the  former  there  is  no  exfoliation, 
the  living  structure  not  having  the  power  to  throw 
off  the  dead  or  necrosed  portion.  Again,  a  dead  part 
in  contact  with  the  living,  does  not  materially  affect 
it.  The  roots  of  the  teeth  depending  for  their  vi- 
tality upon  both  their  internal  and  their  external 
connections,  the  former  of  these  connections  may 
be  destroyed,  without  materially  affecting  the  latter. 
Thus,  a  tooth  may  be  partially  necrosed, — that  is, 
vital  in  one  part  and  dead  in  another, — without  im- 
mediate injury  to  the  living  portion,  and  without 
separation  of  the  living  from  the  dead.  It  is  a  happy 
provision  that  the  analogy  between  the  teeth  and 
the  other  bones  does  not,  in  this  respect,  obtain ;  for 
if  it  did,  we  should  find  the  crowns  of  the  teeth  exfo- 
liated from  the  roots  in  all  cases,  immediately  after 
the  death  of  the  pulp. 

There  results  but  little  change  of  color  to  the  teeth 
from  necrosis,  unless  coloring  matter  is  absorbed  by 
the  dentine  from  the  decomposed  pulp;  though  of 
course  the  lifelike  lustre  and  appearance  of  the 
living  teeth  are  not  present.  Total  necrosis  destroys 
the  entire  organic  connection  of  the  teeth  with  the 
surrounding  parts;  in  which  case  they  are  imme- 
diately expelled  from  their  sockets  as  useless. 

Causes. — Caries  is   a  very  common   cause  of  ne- 


40  INTRODUCTION. 

crosis,  especially  the  partial  form  of  it  to  which 
reference  is  made  above.  Protracted  fever,  or  dis- 
eases of  any  kind  that  diminish  the  vitality  of  the 
constitution,  will  in  a  corresponding  degree  diminish 
that  of  the  teeth,  and  sometimes  destroy  it  entirely. 
Excessive  medication,  especially  with  mercurials,  will 
sometimes  produce  partial,  and  occasionally  total  ne- 
crosis, as  will  also  sometimes  blows  or  violent  shocks, 
when  these  are  not  sufficient  to  displace  the  teeth. 
Great  and  sudden  changes  of  temperature  have  been 
reckoned  causes  of  this  affection ;  but  it  may  well  be 
doubted  whether  they  are  adequate,  without  the  con- 
currence of  other  influences. 


CHAPTER  II. 

CARIES    OF    THE    TEETH. 

Notwithstanding  the  teeth  are  so  important  in 
the  human  economy,  having  functions  so  various  and 
so  extensive  to  perform,  they  are  greatly  neglected 
in  most  instances,  and,  in  many  subjected  to  positive 
violence ;  as,  for  example,  in  crushing  or  biting  hard 
substances,  sustaining  weights,  and  suffering  severe 
percussion,  sudden  extremes  of  temperature,  bungling- 
dental  operations,  etc.  •  Very  few  give  that  attention 
to  these  organs,  which  is  requisite  to  preserve  them 
from  injurious  influences ;  and,  owing  to  artificial 
modes  of  life,  and  consequent  impairment  of  health, 
this  is  often  difficult  to  do.  Indeed,  these  influences 
are  frequently  not  known,  and  the  causes  of  disease 
in  the  teeth  not  explored. 

Such  is  the  truth,  to  some  extent,  in  regard  to 
caries ;  though  this  affection  is  more  generally  a  re- 
sult of  conditions  well  understood.  The  dentine  is 
affected  more  frequently  by  caries  than  by  any  other 
form  of  disease.  It  is  both  frequent  in  occurrence 
and  fatal  in  tendency.     Scarcely  any  that  have  at- 


42  CARIES    OF   THE   TEETH. 

tained  maturity,  are  exempt  from  its  ravages.  It  is  a 
disease  which  the  resisting  forces  can  but  feebly 
withstand,  and  in  which  the  recuperative  powers  are 
of  no  avail.  Some  maintain  that  softened  dentine 
does  in 'many  cases  regain  its  normal  density;  but 
this  cannot  be,  unless  it  retains  its  vitality.  But 
any  agent  possessed  of  sufficient  energy  to  decompose 
the  dentine,  will  destroy  its  vitality.  What  is  that 
decomposition  ?  Either  a  lack  of  vital  power  to 
maintain  the  integrity  of  the  organic  structure,  or 
the  action  of  some  agent  having  an  affinity  for  a  cer- 
tain part  of  the  dentine  more  potent  than  that  vital 
power.  In  either  case,  the  vitality  is  destroyed.  In 
an  organized  structure,  removal  of  one  of  its  compo- 
nent parts  occasions  a  loss  of  vitality  in  the  rest. 

Caries  makes  its  first  attack  upon  the  dentine,  and 
progresses  most  rapidly  in  the  direction  of  the  tubuli. 
There  are  variations  from  this  course ;  as,  for  exam- 
ple, in  the  large  superficial  caries  on  the  labial  sur- 
faces of  the  superior  incisors.  In  many  cases,  too,  it 
advances  immediately  beneath  the  enamel.  Portions 
of  the  dentine  imperfectly  protected  by  the  enamel, 
on  account  either  of  an  injured  condition  or  of  an  im- 
perfect formation  of  the  latter,  are  liable  to  be  at- 
tacked by  this  disease ;  and  points  that,  by  their 
location  or  any  other  unfavorable  circumstance,  re- 
tain injurious  agents  in  contact  with  the  tooth,  are 
very  subject  to  decay. 


CARIES    OF    THE   TEETH.  43 

The  attack  and  progress  of  caries  are  modified  by 
the  constitution  of  the  teeth.  These  may  be  defec- 
tive cither  originally  or  accidentally.  Original  de- 
fectiveness would  extend  to  all  the  teeth  of  the  same 
individual,  whilst  accidental  might  exist  only  as  to 
some  of  the  teeth  in  the  same  mouth,  and  these  only 
at  particular  points.  Such  conditions  are  peculiarly 
favorable  for  the  attack  of  caries.  When  the  whole 
crown  of  the  tooth  is  imperfectly  organized,  the  decay 
will  advance  with  uniform  rapidity,  till  the  whole  is 
destroyed.  But  when  it  is  only  portions  of  the  tooth, 
the  caries,  after  a  time,  becomes  retarded  in  its  prog- 
ress, and  in  some  cases  checked  altogether. 

Among  the  circumstances  which  modify  the  prog- 
ress of  this  disease,  are,  a  change  of  the  condition 
or  character  of  the  agencies  producing  it,  and  an 
increase  or  a  diminution  of  the  amount  of  such  agen- 
cies. The  progress  of  caries  will  also  be  governed 
somewhat  by  the  age  of  the  person  whose  teeth  it 
attacks,  and  by  the  peculiar  constitution  of  the 
organs  themselves;  for,  in  regard  to  constitution, 
these  present  an  almost  infinite  variety,  the  relative 
proportions  of  their  constituents  being  exceedingly 
various,  even  in  persons  of  the  same  age,  and  con- 
tinually varying  in  the  same  person  at  different  ages. 
There  is  a  constant  change  going  on,  the  calcareous 
elements  increasing,  and  the  animal  decreasing.  But 
a  proper  relative  amount  of  elements  may  be  elabo- 


44  CARIES    OF    THE    TEETH. 

rated,  and  yet  a  defective  organization  exist.  This 
condition  arises  from  inipotency  of  the  organizing 
power,  or  from  a  failure  of  the  materials  to  arrange 
and  combine ;  and  it  is  dependent  entirely  on  acci- 
dental causes.  In  vital  energy,  indeed,  the  teeth 
exhibit  great  diversity ;  and  this  corresponds  with, 
and  to  some  extent  depends  upon,  the  vital  energy 
of  the  general  constitution.  Dead  dentine  is  decom- 
posed more  readily  than  living ;  and  hence  the  con- 
clusion that  vitality  resists  caries,  and  that  this  re- 
sistance corresponds  with  the  vigor  of  the  vitality. 

The  points  most  frequently  attacked  by  caries,  are 
the  proximal  surfaces  of  the  teeth,  the  indentations 
and  fissures  on  the  masticating  surfaces  of  the 
molars  and  bicuspids,  the  longitudinal  depressions 
on  the  buccal  and  palatal  walls  of  the  molars,  and 
the  necks  of  the  teeth  at  the  termination  of  the 
enamel.  On  the  proximal  surfaces,  the  enamel  is 
thinner  than  elsewhere ;  and  the  situation  is  pecu- 
liarly favorable  for  the  accumulation  and  retention 
of  injurious  agencies.  The  union  of  the  enamel  in 
the  fissures  and  indentations  of  the  crowns  of  the 
molars,  is  often  imperfect ;  and  thus  there  is  a  way  of 
entrance  for  vitiated  fluids  to  the  dentine.  Decay  is 
found  at  the  terminations  or  intersections  of  these 
fissures  earlier  than  at  any  intermediate  points.  The 
indentations,  or  grooves,  on  the  sides  of  the  teeth,  are 
usually  attacked  by  caries  at  that  point  next  to  the 


CARIES    OF    THE    TEETH.  45 

neck.  Less  frequently,  the  disorder  is  exhibited  at 
the  neck,  just  beneath  the  border  of  the  enamel, 
under  which  it  burrows  with  a  transverse  extension. 

The  order  in  which  the  elements  are  removed,  is 
governed  by  the  nature  of  the  agency  which  effects 
the  decomposition ;  and  this  is  usually  one  having  an 
affinity  for  the  calcareous  elements  strong  enough  to 
destroy  the  texture  of  the  dentine,  and  remove  the 
earthy  portion.  Those  acids  which  have  an  affinity 
for  the  lime  of  the  dentine,  produce  its  decomposition 
in  this  manner.  When  the  decay  is  thus  caused, 
the  portion  remaining  in  the  cavity  is  soft,  and 
approximates  the  gelatinous  condition  as  the  cal- 
careous material  is  abstracted.  Agents  of  a  different 
character,  too,  often  produce  decay.  Alkalies  will  act 
upon  the  animal  portion  of  the  dentine,  and  remove 
it ;  and  in  caries  thus  produced,  the  residue  is  friable 
and  chalklike.  In  other  cases  the  constituents  are 
simultaneously  removed.  Nitric  acid  will  cause  an 
entire  breaking-up  of  both  the  earthy  and  the  animal 
constituents.  Death  of  the  dentine  generally  induces 
decay,  decomposition  being  more  easy  after  the 
vitality  is  lost.     But  there  are  exceptions  to  this. 

The  dentine  outside  of  the  decay  may  be  in  an  in- 
flamed and  irritable  condition,  so  that  contact  with 
the  decayed  portion  will  produce  pain ;  and  thus  we 
may  be  led  falsely  to  conclude  that  the  softened  den- 
tine is  sensitive;  and,  indeed,  it  is  maintained  that 


46  CARIES    OF    THE    TEETH. 

in  some  cases  the  partially  decomposed  dentine  is  so, 
on  the  supposition  that  a  small  portion  of  the  calca- 
reous elements  may  be  removed,  and  yet  the  fila- 
ments of  the  nerve  ramifying  the  part,  not  be  de- 
stroyed. 

The  progress  of  caries  is  far  more  rapid  in  the 
crowns  of  the  teeth  than  in  the  roots,  for  the  reason 
that  the  former  are  more  exposed  to  the  influences  of 
external  injuries.  It  is  true  that  the  crowns  are 
covered  by  enamel,  which  is  designed  to  shield  the 
dentine  from  injury,  but  which  is  often  defective,  and 
on  which  are  accumulated  agencies  that  it  cannot  re- 
sist, even  when  it  is  perfect ;  so  that  the  enamel  itself 
is  sometimes  decomposed.  The  roots,  too,  possess  a 
higher  degree  of  vitality  than  the  crowns,  and  their 
ability  to  resist  the  encroachments  of  decay  is  cor- 
respondingly greater;  and  hence  we  often  find  the 
roots  of  teeth  solid  and  free  from  decay,  the  crowns 
of  which  have  been  removed  by  rapid  decomposition. 
Injurious  substances  are  sometimes  pressed  into  con- 
tact with  the  dentine,  through  defects  in  the  enamel, 
or  under  its  projections,  and  there  retained  till  their 
mischievous  effect  is  produced. 

It  is  maintained  by  some  writers  that  caries  is  con- 
tagious. Dr.  Koecker  was  of  this  opinion.  The 
question,  then,  is,  whether  there  is  any  property  in 
the  decayed  dentine  of  one  tooth,  capable  of  producing 
the  same  condition  in  the  healthy  dentine  of  an  other. 


CARIES    OF   THE    TEETH.  47 

The  residue  of  abnormal  dentine  in  the  soft  decay, 
consists  of  the  animal  elements  and  a  small  portion 
of  earthy  material ;  and  in  decay  in  which  the  gela- 
tinous constituent  is  abstracted,  the  remainder  is 
chalklike,  consisting  mainly  of  phosphate  of  lime. 
In  neither  of  these  is  there  anything  that  can  possi- 
bly operate  on  the  healthy  dentine.  There  is  one 
thing  here,  however,  that  is  worthy  of  remark,  and 
that  lias  perhaps  led  to  the  mistaken  notion  that 
caries  is  contagious  :  decayed  dentine  will  absorb  and 
retain  fluids  that  injuriously  affect  sound  dentine; 
and  when  the  decay  is  on  the  proximal  portion,  two 
teeth  are  subject  to  the  same  exciting  cause.  But  it 
is  seldom  that  two  teeth  thus  situated  are  both  in 
the  same  stage  of  decay;  a  fact  principally  attributa- 
ble to  the  difference  in  their  constitution.  The  decay 
of  the  teeth  in  pairs  has  also  been  adduced  as  evi- 
dence of  the  contagious  character  of  the  disease. 
This,  however,  results  from  the  fact  that  the  pairs 
are  formed  at  the  same  time ;  are  subject  to  the 
same  influences  in  their  formation,  and  hence  are 
constituted  alike ;  and  if  one  of  the  pair  is  defective, 
the  other  will  be  in  a  like  condition.  When  there  is 
a  vitiation  of  the  saliva  or  mucus,  they  will  be  simi- 
larly affected.  In  no  common  acceptation  of  the 
term  contagious,  can  it  be  applied  to  caries  of  the 
teeth. 

The  color  of  caries  is  exceedingly  various,  from 


48  CARIES    OF    THE    TEETH. 

that  of  healthy  dentine,  through  every  intermediate 
shade,  to  jet  black.  The  rate  of  the  progress  is  indi- 
cated by  the  color  of  the  decay,  being  slower  as  this 
is  darker,  so  that  when  the  decay  becomes  almost 
stationary,  the  affected  portion  is  black.  The  degrees 
of  color  are  differently  enumerated  by  different 
writers;  as,  by  Koecker  five,  by  others  seven,  and 
so  on.  Three,  however,  are  sufficient  for  our  pur- 
pose :  white,  brown,  and  black.  The  sensitiveness  of 
the  dentine  is  greatest  in  teeth  affected  by  the  white 
decay,  and  usually  decreases  as  the  color  darkens ; 
though  there  are  exceptions  to  this  rule ;  for  occa- 
sionally we  find  teeth  affected  by  dark  decay,  that 
are  quite  sensitive.  The  light-colored  decay  is  more 
difficult  to  arrest  than  the  dark.  In  many  cases  of 
the  former,  filling  seems  hardly  to  retard  its  pro- 
gress; whereas,  in  the  latter,  by  proper  filling,  the 
advance  of  the  decay  may  be  checked  altogether. 
The  cause  of  the  dark  color  of  caries  is  not  perfectly 
comprehended.  It  is  doubtless  a  deposit  upon  the 
decayed  part,  and  is  most  probably  a  metallic  oxyd, 
as  iron,  sodium,  potassium,  and  calcium  are  found  in 
the  saliva  and  mucus  in  several  combinations. 

The  opinion  is  entertained  by  some,  that  this 
deposit  protects  the  dentine  from  the  influence  of 
injurious  agents.  But  this  is  most  probably  not  cor- 
rect, at  least  to  any  perceivable  extent.  If  the 
deposit  does  thus  serve  as  a  protection,  the  removal 


CARIES    OF    THE    TEETH.  49 

of  the  discolored  portion  would  subject  the  dentine  to 
a  renewed  attack  of  caries,  which  experience  assures 
us  it  does  not  do,  but  that  after  some  time  it  assumes 
the  dark  hue  again.  Those  who  maintain  this 
opinion,  refer,  in  support  of  it,  to  the  fact  that  a 
deposit  of  oxyd  of  silver  being  made  upon  a  decay 
of  light  color,  by  the  use  of  nitrate  of  silver,  the  prog- 
ress of  the  decay  is  thereby  retarded.  This  retardal, 
however,  is  effected  more  probably  by  a  change  in 
the  character  of  the  decay,  than  by  any  protection 
afforded  by  the  coating  of  oxyd  of  silver. 

Some  sensitiveness  commonly  accompanies  caries. 
It  does  not  often  amount  to  pain,  but  is  rather  a 
sense  of  uneasiness ;  yet,  when  anything  is  brought 
in  contact  with  the  sensitive  dentine,  as  sudden 
changes  of  temperature,  acids,  etc.,  intense  pain  may 
be  produced.  Dr.  Koecker  remarks  that  caries  is 
most  tender  in  its  first  stages ;  and  Dr.  Cone,  that 
when  a  tooth  is  attacked  by  it,  the  sensitiveness  is 
increased.  The  surface  of  the  dentine,  or  that  part 
united  to  the  enamel,  is  susceptible  of  the  most  acute 
sensitiveness,  since  here  is  the  place  of  termination 
of  the  nerve-fibrils  which  ramify  the  dentine,  and 
which,  whether  in  a  healthy  or  a  diseased  state,  are 
more  sensitive  at  their  terminations  than  along  their 
extent.  "When  there  is  inflammation  of  the  dentine, 
intense  pain  may  be  produced  by  the  contact  of  an 
instrument,  in  a  cavity  of  decay,  at  the  line  of  union 

D 


50  CARIES    OF    THE   TEETH. 

of  the  dentine  with  the  enamel,  and  very  little  sensi- 
tiveness be  present  elsewhere  in  the  cavity.  Sensi- 
tiveness of  a  uniform  character  sometimes  pervades 
all  parts  of  the  cavity,  while  at  other  times  it  may 
be  very  intense  at  one  point,  and  very  slight  or 
entirely  absent  at  any  other.  A  thin  lamina  of  the 
dentine  lining  the  whole  cavity,  may  be  uniformly 
sensitive,  and  in  some  cases  this  sensitiveness  may 
involve  the  entire  body  of  the  dentine. 

By  means  of  this  sensitiveness,  warning  is  trans- 
mitted to  the  pulp,  which  emits  osseous  material  with 
increased  energy ;  and  thus  a  process  of  filling  up 
the  natural  cavity  of  the  tooth  is  instituted,  that  the 
decay  may  not  encroach  upon  the  nerve.  But  this 
warning  may,  in  some  degree,  be  transmitted  to  the 
pulp,  though  there  be  no  increase  of  sensitiveness. 

This  sensitiveness  is  modified  by  the  character  of 
the  teeth,  the  nature  of  the  decay,  and  the  state  of 
the  patient's  constitution.  The  teeth  of  the  same 
person  will  be  more  sensitive  at  one  time  than  at 
another,  because  of  a  greater  irritability  of  the  ner- 
vous system.  Those  teeth  which  decay  most  rapidly, 
are  usually  most  sensitive;  though  in  teeth  whose 
vitality  is  lost  considerably  in  advance  of  their  decay, 
there  is  no  sensitiveness  at  all.  Except  in  such  cases 
as  last  mentioned,  the  whitest  and  most  rapid  decay 
has  most  sensitiveness,  the  brown  much  less,  and  the 
black  scarcely  any. 


CAUSES  OF  CARIES.  51 


CAUSES  OF  CARIES. 


The  causes  of  caries  of  the  teeth  may  be  considered 
under  two  general  divisions — predisposing  and  ex- 
citing. Of  the  former,  some  are  original,  others  acci- 
dental. The  original  development  of  the  constitu- 
tion may  be  defective,  either  from  original  or  from 
accidental  defect  in  the  parent;  but  more  certainly 
from  the  former.  Constitutional  characteristics  are 
transmissible,  and  a  defect  is  as  surely  hereditary  as 
anything  else.  In  the  fetus,  during  gestation,  there 
may  have  originated  germs  from  which  perfect  organs 
can  never  be  developed,  and  these  germs  may  be 
more  or  less  defective  according  to  the  constitutional 
condition  of  the  mother,  or  according  to  accidental 
conditions  to  which  she  may  be  subject,  and  which 
may  seriously  affect  the  fetus.  After  birth,  too,  the 
child  is  exposed  to  injurious  impressions,  which  will, 
to  a  greater  or  less  degree,  render  the  development 
defective;  as  imperfect  nourishment  and  the  diseases 
and  functional  derangements  peculiar  to  childhood. 
A  diseased  condition,  or  functional  derangement,  will 
interrupt  the  proper  elimination  and  perfect  upbuild- 
ing of  the  materials  necessary  for  the  perfect  struct- 
ure ;  and  indeed  anything  that  will  disturb  the 
equilibrium  of  action  in  the  system,  may  be  detri- 
mental to  the  teeth. 

In  some  instances  the  teeth  will  exhibit  the  pecu- 


52  CARIES    OF    THE    TEETH. 

liarities  of  the  mother,  and  in  others,  those  of  the 
father ;  while  sometimes  they  participate  those  of 
both  parents ;  and  when  the  parental  imprint  is  thus 
found  stamped  on  the  teeth,  it  will  also  be  found  that 
those  of  the  same  class  decay  at  the  same  point  and 
at  about  the  same  age  as  in  the  ancestor.  In  such 
cases  the  defect  is  manifestly  hereditary ;  it  cannot 
be  accidental :  the  coincidences  thus  constantly  oc- 
curring preclude  any  other  conclusion.  Hereditary 
taint,  then,  may  be  regarded  as  a  predisposing  cause 
of  caries. 

Impaired  vitality  is  another  predisposing  cause  ; 
and  not  only  impaired  vitality  of  the  teeth  and  con- 
tiguous parts,  but  also  that  of  the  general  system. 
Indeed,  the  vital  vigor  of  the  teeth  depends  upon 
that  of  the  general  system,  and,  when  there  is  no 
local  influence  at  work,  corresponds  with  it ;  so  that 
when  the  general  system  is  in  the  most  healthy  con- 
dition, the  teeth  possess  the  greatest  power  of  resist- 
ance to  deleterious  agencies.  This  resisting  power  is, 
at  best,  comparatively  feeble ;  but  its  feebleness  is,  to 
some  extent,  compensated  by  the  peculiar  structure 
of  the  teeth,  which  is  less  liable  to  decomposition 
than  any  other  part  of  the  human  body.  Yet  the 
integrity  of  these  organs  depends  much  on  the  main- 
tenance of  a  healthy  vitality,  and  this  on  that  of  the 
general  system.  A  dead  tooth  will  decay  far  more 
rapidly  than  a  living  one  in  similar  circumstances ; 


CAUSES    OF    CARIES.  53 

and  hence  the  conclusion  that  vitality  resists  inju- 
rious agents,  and  that  the  resistance  will  be  propor- 
tionate to  the  vitality. 

All  febrile  conditions  promote  and  facilitate  decay, 
and  frequently  in  two  ways :  by  diminishing  the 
general  vitality,  and  by  changing  the  secretions  of 
the  mouth  so  that  these  act  injuriously  upon  the 
teeth.  Accompanying  such  conditions,  there  is  gene- 
rally inflammation  of  the  dentine ;  and  in  such  cases, 
this  always  partakes  of  the  general  disorder  so  as  to 
become  very  susceptible  to  injury.  All  diseases, 
indeed,  that  impair  the  vitality  and  change  the  secre- 
tions, may  be  considered  predisposing  causes  of  decay, 
and  some  even  more;  dyspepsia,  for  instance,  being 
not  only  predisposing,  but  also  exciting,  since  it  pre- 
pares in  the  stomach  an  acid  that  is  almost  continu- 
ally thrown  upon  the  teeth,  and  that  acts  upon  them 
with  great  energy.  Residence  in  miasmatic  regions, 
is  also  a  predisposing  cause,  inducing  unfavorable 
conditions. 

Diminished  vitality  may  result  either  from  consti- 
tutional or  from  local  causes.  These  latter  are  such 
as  produce  an  irritable  or  diseased  condition  of  the 
immediate  parts,  or  an  abnormal  condition  of  the 
dentine,  without  the  power  to  effect  its  decomposi- 
tion. Local  causes  of  a  diminution  of  vitality  are 
not  in  their  character  so  formidable,  and  not  so  diffi- 
cult to  control,  as  those  which  are  constitutional. 


54  CARIES    OF   THE   TEETH. 

Many  medicinal  agents  are  regarded  as  predis- 
posing causes  of  caries ;  and  among  these,  mercurials 
occupy  a  prominent  place.  They  operate  by  vitiating 
the  secretions  of  the  mouth,  and  producing  an  abnor- 
mal condition  of  the  periosteum  about  the  fangs  of 
teeth,  the  mucous  follicles,  and  the  salivary  glands. 
Some  entertain  the  opinion  that  the  abnormal  action 
of  the  absorbents,  induced  by  mercurials,  predisposes 
to  decay. 

Dental  operations  performed  at  an  improper  time 
and  in  an  improper  manner,  may  be  reckoned  among 
the  predisposing  causes  of  caries.  The  vitality  of  the 
teeth  may  be  thus  impaired,  or  a  diseased  condition 
established,  or  the  part  operated  upon  may  be  per- 
mitted to  remain  rough,  so  that  foreign  substances 
will  be  retained,  and,  becoming  vitiated,  produce  a 
deleterious  effect.  Often,  from  an  improper  use  of 
the  file,  extensive  inflammation  of  the  dentine  super- 
venes, which  is  sometimes  followed  by  death  of  the 
tooth,  and  by  disease  of  the  contiguous  parts.  Arti- 
ficial substitutes  imperfectly  adapted,  are,  in  many 
instances,  the  occasion  of  caries;  not  that  clasps  or 
the  edges  of  the  plate  tend  directly  to  injure  the 
tooth,  but  the  agencies  superinduced  by  them  do, 
and  especially  when  the  material  used  is  not  of  the 
right  quality. 

Lack  of  proper  exercise  in  mastication  induces  a 
condition    that   is  favorable    to    decay.     It  does  so, 


EXCITING   CAUSES    OF   CARIES.  55 

however,  rather  by  favoring  injurious  agents  to  act 
on  the  teeth,  than  by  imparting  any  direct  predispo- 
sition to  the  teeth  themselves.  Substances  of  all 
kinds  are  deposited  much  more  rapidly  when  the 
teeth  are  idle. 

The  teeth  cannot,  with  impunity,  undergo  sudden 
transitions  from  one  extreme  of  temperature  to 
another,  or  even  such  extremes  as  may  be  endured 
by  the  surrounding  parts.  By  these,  inflammation  of 
the  dentine  may  be  induced,  and  the  vitality  of  the 
teeth  diminished,  so  that,  even  in  friable  teeth, 
checking  of  the  enamel  will  occur,  and  thus  a  condi- 
tion arise  that  will  facilitate  decay. 

EXCITING    CAUSES    OF    CARIES. 

When  there  is  a  predisposition  to  caries,  any  of  the 
exciting  causes  act  with  more  vigor.  Teeth  that  are 
well  constituted,  and  that  have  retained  unimpaired 
health  and  vitality,  withstand  influences  that,  in  less 
favorable  circumstances,  destroy  them  in  a  very  short 
time.  The  immediate  cause  of  decay  is  the  action  of 
agents  chemically  upon  the  teeth.  It  is  not  here 
proposed  to  enter  upon  an  investigation  of  the  man- 
ner in  which  these  various  agents  operate ;  for  that 
would  open  up  a  vast  field  for  exploration — a  field 
outside  of  the  province  of  this  work.  The  sources  of 
these  agents,  however,  are  several :  as,  vitiated  secre- 


56  CARIES    OF    THE    TEETH. 

tions  of  the  mouth,  the  saliva,  and  the  mucus;  abnor- 
mal secretion  from  the  stomach ;  decomposition  of 
animal  and  vegetable  substances  in  the  mouth ;  acids 
taken  with  food,  or  administered  as  medicines;  and 
galvanic  action. 

Sometimes  the  secretions  of  the  mouth  are  wholly 
acid,  and  thus  these  natural  products,  so  vitiated,  be- 
come instruments  of  mischief.  The  natural  state  of 
the  mucus  is  acid,  but  that  of  the  saliva  alkaline ; 
so  that  these  secretions  counteract  each  other;  but 
when  the  saliva  and  the  mucus  are  both  acid,  the 
teeth  must  suffer.  These  secretions  may  become 
vitiated,  through  inability  of  the  glands,  from  disease 
or  an  enfeebled  condition,  perfectly  to  perform  their 
functions ;  or  the  blood  may  be  in  an  abnormal  state, 
and  the  glands  unable,  on  that  account,  though  they 
were  healthy,  as  they  seldom  are  in  such  case,  to 
elaborate  healthy  saliva:  when  the  fountain  is  cor- 
rupt, the  stream  cannot  be  pure.  Thus,  anything 
that  produces  a  diseased  condition  of  the  blood,  tends 
to  the  decay  of  the  teeth ;  and  such  diseased  condi- 
tion often  has  a  direct  injurious  effect  on  the  secre- 
tive apparatus,  and  so  works  a  double  harm. 

But  to  the  theory  of  the  pernicious  influence  of  the 
saliva,  it  may  be  objected,  that,  if  it  were  true,  all 
parts  of  the  teeth  would  be  alike  affected.  This 
objection,  however,  will  lose  its  force  when  it  is  con- 
sidered that  the  teeth,  in  many  cases,  are  not  equally 


EXCITING   CAUSES    OF    CARIES.  57 

well  organized  in  all  their  parts ;  that  some  parts  are 
not  so  well  protected  as  others ;  and  that  between  the 
teeth  there  is  room  for  the  retention  of  saliva  and 
foreign  substances,  which  there  combine  their  influ- 
ence upon  them.  In  cases  in  which  there  is  a  great 
quantity  of  viscid  saliva  constantly  flowing,  the  teeth 
decay  very  rapidly.  The  decay  is  of  a  light  color ; 
so  light,  indeed,  that,  in  many  instances,  it  is  difficult 
to  distinguish  it,  by  this,  from  undecomposecl  dentine. 
The  gastric  fluid  often  becomes  deranged  by  irrita- 
tion or  disease  of  the  stomach,  so  that  the  function 
of  the  latter  is  very  imperfectly  performed,  and  fer- 
mentation of  the  food  occurs,  evolving  agents  that 
injuriously  affect  the  teeth.  In  dyspepsia,  such 
agents  are  often  brought  in  contact  with  the  teeth  by 
eructation  and  vomiting-  and  the  diseased  gastric 
fluid,  which  contains  a  large  proportion  of  hydro- 
chloric acid,  is  also  thus  brought  in  contact  with 
them,  acting  upon  them  with  great  violence.  After 
food  commingled  with  this  secretion  is  ejected  from 
the  stomach,  the  teeth  will  be  found  eroded  over  all 
their  surfaces.  Dyspeptics  will  appreciate  this  re- 
mark. In  such  cases,  if  the  teeth  are  not  of  superior 
organization,  they  are  destroyed  in  a  short  time. 
Their  surfaces  thus  roughened,  afford  a  lodgment  for 

foreign  substances  on  all  parts. 
< 

The  most  common  agents,  however,  that  injure  the 
teeth,  are  originated  in  the  mouth,  by  the  decompo- 


58  CARIES    OF   THE   TEETH. 

sition  of  animal  and  vegetable  matter.  By  this  pro- 
cess, elements  are  eliminated,  that  form  new  combi- 
nations, and  these  operate  as  refined  instruments  in 
the  destruction  of  the  teeth.  Favorable  conditions 
exist  in  the  mouth  for  such  decomposition,  and  also 
for  such  new  combinations ;  for  there  is  a  sufficient 
amount  of  heat  and  moisture;  and  both  of  these, 
especially  the  former,  facilitate  the  action  of  any  acid 
upon  the  dentine.  The  character  of  the  saliva  and 
mucus  will  very  much  modify  the  decomposition  of 
foreign  substances  in  the  mouth.  If  these  secretions 
are  both  acid,  the  decomposition  will  be  much  more 
rapid,  and  more  potent  in  its  effect. 

Again,  it  is  sometimes  the  case  that  the  salivary 
glands  are  comparatively  inactive,  except  when  spe- 
cially excited,  and  yet  the  mucous  glands  still  effi- 
cient, eliminating  their  secretion ;  so  that  the  mouth 
assumes  an  acid  condition,  because  there  is  not  saliva 
sufficient  to  neutralize  the  mucus;  in  which  condition 
decomposition  of  foreign  substances  would  be  greatly 
accelerated.  There  are  many  cases,  however,  in 
which  the  flow  of  saliva  is  copious,  and  yet  the  decay 
very  rapid  ;  which  is  in  consequence  of  an  acid  con- 
dition of  both  secretions,  or  of  a  rapid  decomposition 
of  foreign  substances  in  the  mouth. 

There  are  acids  taken  with  the  food  that  act  di- 
rectly upon  the  teeth ;  as  acetic  acid,  or  vinegar. 
Professor  Westcot  says :  "  Acetic  and  citric  acids  so 


EXCITING    CAUSES    OF    CARIES.  59 

corroded  the  enamel  in  fortyeight  hours,  that  much 
of  it  was  easily  removed  with  the  fingernail."  And 
"  Malic  acid,  or  the  acid  of  apples,  in  its  concentrated 
state,  also  acts  promptly  upon  the  teeth."  Now, 
these  acids,  in  the  use  of  many  kinds  of  food,  are 
brought  into  frequent  contact  with  the  teeth.  In 
the  manufacture  of  vinegar,  sulphuric  acid  is  often 
employed;  so  that  in  this  article  of  food  we  have 
that  acid  either  alone  or  combined  with  the  acetic, 
the  former  acting  with  greater  energy  upon  the  teeth 
than  the  latter.  Acetic  acid  also  facilitates  the  de- 
composition of  food  retained  in  the  mouth,  and  thus 
reproduces  itself  in  abundance. 

After  eating  apples  that  contain  a  great  amount  of 
malic  acid,  the  teeth  will  be  found  corroded  over  all 
their  surfaces.  This  acid,  as  well  as  the  others,  af- 
fects the  enamel  somewhat,  and  when  the  latter  is 
very  thin,  though  it  may  not  be  all  removed  from 
any  particular  point,  yet  its  integrity  will  be  de- 
stroyed, so  as  to  be  readily  fractured,  thus  admitting 
injurious  agents  in  contact  with  the  dentine,  which  is 
much  more  susceptible  of  injury  from  acids  than  the 
enamel :  points  imperfectly  protected  by  this  are  vio- 
lently attacked  by  acetic,  malic,  and  sulphuric  acids. 
In  decayed  cavities  these  agents  produce  rapid  re- 
sults. They  should  be  as  much  as  possible  avoided, 
and,  when  necessarily  used,  should  be  removed  from 
the  teeth  by  cleaning  with  great  care.     It  would  be 


60  CARIES    OF    THE    TEETH. 

safest  to  employ  some  neutralizing  agent  after  the 
use  of  any  acids  with  food.  During  mastication, 
there  is  an  increased  secretion  of  saliva,  which,  if  in 
a  healthy  state,  will  tend  to  neutralize  any  acid  that 
may  at  the  time  be  present,  and  also,  by  its  flow,  to 
remove  foreign  substances  from  the  mouth. 

Salts  may  be  decomposed  in  the  mouth,  and  their 
acids  act  upon  the  teeth;  as  when  the  acid  of  the  salt 
has  a  stronger  affinity  for  any  element  of  the  tooth- 
bone  than  for  the  base  with  which  it  is  combined. 
Many  medical  preparations  contain  agents  peculiarly 
deleterious  to  the  teeth ;  acids  being  especially  in 
requisition  for  these,  and  not  in  homeopathic  dilu- 
tions, either.  The  acids  most  commonly  thus  admi- 
nistered are  the  hydrochloric,  the  nitric,  the  sulphu- 
ric, the  acetic,  the  tartaric,  and  the  citric,  any  one  of 
which  will  produce  direct  and  rapid  decomposition  of 
the  dentine,  even  when  unaided  by  the  temperature 
of  the  mouth.  These  acids  are  often  administered 
by  physicians,  without  any  regard  to  their  nature  or 
their  influence  upon  the  teeth.  Sometimes,  however, 
they  are  given  through  a  tube;  though  this  method 
generally  does  not  amount  to  much  as  a  precau- 
tionary measure,  for  in  most  instances  the  fluid  comes 
in  contact  with  all  parts  of  the  mouth.  A  subse- 
quent rinsing  of  the  mouth  with  water  effects  only  a 
dilution,  not  an  entire  removal  of  the  acid.  In  order 
wholly  to  counteract  their  injurious  influence  upon 


EXCITING    CAUSES    OF    CARIES.  61 

the  teeth,  an  alkaline  solution  should  be  used  after 
the  administration  of  such  medicines. 

Galvanic  action  is  a  cause  of  decay  of  the  teeth, 
only  so  far  as  it  is  a  means  of  decomposing  com- 
pounds which  are  in  the  mouth,  and  the  elements  of 
which,  according  to  the  laws  of  affinity,  form  other 
compounds,  some  of  which  are  highly  prejudicial  to 
the  teeth.  The  elements  hydrogen,  nitrogen,  and 
oxygen,  may  thus  be  set  free  from  animal  and  vege- 
table substances,  when  they  will  at  once  seek  other 
elements  with  which  to  combine ;  and  the  character 
of  the  combinations  will  be  determined  by  the  nature 
of  the  elements,  and  by  the  attendant  circumstances. 
These  compounds  will  frequently  be  of  an  acid  char- 
acter. 

Such  an  arrangement  may  exist  as  will  maintain  a 
constant  galvanic  action,  whose  legitimate  effects  will 
be  as  constant  upon  the  teeth ;  and  this  ceaseless 
process  cannot  but  make  its  mark.  It  is  a  favorable 
arrangement  for  galvanic  action  when  there  are  two 
or  three  kinds  of  metals  in  the  mouth  at  once,  par- 
ticularly if  these  are  such  as  differ  in  their  affinities 
for  oxygen.  In  some  cases  three  or  four  kinds  of 
metals  are  employed  in  filling  teeth  of  the  same 
mouth ;  in  some,  fillings  of  one  metal  and  a  plate  of 
another;  and  in  others,  plates  of  so  few  carats  are 
used  that  they  oxydize  rapidly  in  the  mouth,  without 
the  aid  of  any  other  metal. 


62  CARIES    OF    THE    TEETH. 


COMPARATIVE    LIABILITY   TO    DECAY. 

All  classes  of  teeth  are  not  alike  liable  to  decay. 
Their  difference  in  this  respect  may  arise  from  a  dis- 
similarity in  their  organic  structure,  the  best  organized 
being  the  most  capable  of  resisting  disease;  or  from  a 
concentration  of  the  destructive  agency  upon  the 
tooth  first  affected.  The  first  molars  are  much  more 
liable  to  decay  than  any  other  teeth,  since  they  are 
less  perfectly  developed  than  those  formed  at  a  later 
period  of  life.  They  are  the  first  permanent  teeth 
irrupted,  and  are  subjected  to  all  the  irritating  con- 
ditions consequent  on  the  removal  of  the  temporary, 
and  the  irruption  of  the  other  permanent  teeth.  But 
these  conditions,  in  many  cases,  produce  no  apparent 
injury  upon  them,  they  maintaining  their  integrity 
till  all  the  other  permanent  teeth  are  irrupted,  and 
then  decaying  earlier  than  any  others.  In  such 
cases,  the  decay  is  a  result  of  influences  more  efficient 
than  those  occurring  on  the  irruption  of  the  other 
teeth. 

After  the  first,  the  second  molars  are  most  subject 
to  caries ;  and  after  these  the  second  bicuspids.  The 
latter  two  classes  doubtless  are  so  subject,  more  from 
the  facility  they  afford  to  the  lodgment  of  deleterious 
substances,  than  from  a  relatively  imperfect  organiza- 
tion.    Besides,  from  six  to  fifteen  years  of  age,  the 


COMPARATIVE    LIABILITY    TO    DECAY.  63 

teeth  are  less  appreciated  and  less  cared  for  than  at 
a  later  period  of  life.  The  next  most  liable  to  decay 
are  the  third  molars.  Then  follow  in  order  the  first 
bicuspids,  the  lateral  incisors,  the  central  incisors,  and 
the  cuspids.  Below  are  appended,  in  tabular  form, 
one  thousand  cases  of  decayed  teeth,  as  observed 
under  ordinary  circumstances,  exhibiting  the  number 
and  per  cent,  of  these  in  each  class : — 

26,  or    2A  per  cent.,  in  central  incisors. 

38,  or    3f  "  in  lateral  incisors. 

24,  or    2$  "  in  canines. 

87,  or    8f  "  in  first  bicuspids. 

134,  or  13|  "  in  second  bicuspids. 

370,  or  37  "  in  first  molars. 

218,  or  22f  "  in  second  molars. 

102,  or  10J  "  in  third  molars. 

Of  these,  a  large  proportion  were  removed  for  relief 
from  disease  originating  in  caries  of  the  dental  tissue. 
In  general,  the  superior  teeth  are  liable  to  decay 
earlier  and  more  rapidly  than  the  inferior. 


CONSEQUENCES    OF   CARIES. 

It  is  here  proposed  to  refer  only  to  some  of  the 
more  common  results  of  this  affection,  one  of  the 
most  obvious  of  which  is  the  exposure  of  the  pulp  of 
the  tooth;    on  which  exposure,  disease   ensues,  and 


64  CARIES    OF    THE    TEETH. 

finally  death.  During  this  diseased  condition  of  the 
pulp,  there  occurs  that  very  peculiar  sensation  com- 
monly denominated  toothache.  As  well  as  the 
destruction  of  the  pulp,  the  entire  destruction  of  the 
crown  of  the  tooth  is  the  inevitable  consequence  of 
caries,  unless  this  is  interrupted  in  its  progress. 
After  the  destruction  of  the  pulp  and  the  lining 
membrane,  the  external  periosteum  in  many  cases 
becomes  involved,  the  affection  being  but  an  exten- 
sion of  that  which  destroyed  the  internal  periosteum. 
Inflammation  and  suppuration  are  of  common  occur- 
rence, by  which  a  discharge  is  established  from  be- 
tween the  margin  of  the  gum  and  the  neck  of  the 
tooth,  or  through  a  fistulous  opening  in  the  process 
and  the  gum,  as  is  the  case  when  an  abscess  is  formed 
at  the  point  of  a  root. 

A  diseased  condition  of  the  alveolar  process  is,  in 
many  instances,  produced  by  diseased  and  dead  teeth  ; 
necrosis  and  an  exfoliation  of  considerable  portions 
being  sometimes  the  effect.  Indeed,  extensive  caries 
of  the  jaw  is  occasionally  thus  produced.  Disease  of 
the  antrum,  too,  is  very  generally  induced  or  greatly 
aggravated  by  the  same  cause.  Tumors,  sometimes 
of  a  malignant  character,  connected  either  with  the 
bony  or  with  the  soft  parts,  not  unfrequently  spring 
from  this  source,  particularly  in  constitutions  of  a 
cancerous  diathesis.  Great  nervous  derangement 
may  result,  either  in  whole  or  in  part,  from  decayed 


CONSEQUENCES    OF    CARIES.  65 

teeth,  as  does  very  frequently  facial  neuralgia,  which 
is  sometimes  confined  to  a  single  nerve-branch  in  the 
immediate  vicinity  of  the  irritating  cause,  sometimes 
ramified  over  the  whole  side  of  the  face  and  head, 
and  occasionally  spread  much  farther,  so  as  even  to 
implicate  the  shoulder  and  the  arm.  Neuralgia  of 
these,  extending  down  to  the  hand,  is  often  found  to 
be  instantly  relieved  by  extraction  of  a  diseased 
tooth ;  and  any  operator  of  much  observation  can 
call  to  mind  numerous  instances  in  which  facial  neu- 
ralgia has  been  thus  relieved  or  wholly  cured.  This 
affection  of  the  face,  however,  does  not  always  origi- 
nate in  diseased  teeth ;  though  there  is  little  doubt 
that,  in  a  majority  of  cases,  it  rises  wholly  or  par- 
tially from  this  cause. 

Inflammation  of  the  mucous  membrane  of  the 
mouth,  is  a  common  result  of  diseased  teeth  ;  and  it  is 
liable  to  extend  to  distant  parts  of  this  membrane, 
and  occasion  greater  difficulty  than  in  the  mouth,  as 
would  especially  be  the  case  when  there  is  an  irri- 
table condition  of  the  throat  and  bronchia;  and  the 
esophagus  and  stomach  would  not  be  exempt.  In 
what  degree  such  an  implication  of  the  respiratory 
and  the  digestive  apparatus  is  referable  to  diseased 
teeth,  it  may  not  be  easy  to  determine ;  but  it  is 
impossible  that  a  number  of  such  teeth,  involving  in 
their  disease  all  the  ramifications  of  the  facial  nerves 
and  the  whole  mucous  membrane  of  the  mouth,  could 


66  CARIES    OF    THE    TEETH. 

remain  there  with  impunity.  And  besides  this  direct 
influence  on  the  lungs  and  stomach,  diseased  teeth 
are  constantly  emitting  offensive  odors,  which  are 
taken  in  by  inhalation,  and  offensive  matter,  which  is 
swallowed  with  the  food. 

TREATMENT    OF    CARIES. 

In  the  rational  treatment  of  caries,  the  first  con- 
siderations are  the  nature  and  peculiarities  of  the 
obvious  predisposing  causes ;  whether  these  are  con- 
stitutional or  local;  and  if  constitutional,  whether 
they  are  such  as  can  be  modified  by  therapeutic 
treatment  of  the  general  system.  If  the  latter,  such 
treatment  should  be  adopted  as  will  bring  about  the 
most  perfect  state  of  health,  so  as  to  obviate  as  far  as 
possible  all  conditions  favorable  to  decay,  by  securing 
a  healthy  state  of  the  mouth  in  all  its  parts — as  the 
gums,  the  mucous  membrane,  the  salivary  glands. 
The  teeth  should  be  kept  free  from  all  deposits  and 
accumulations  of  whatever  character;  for,  though 
some  of  these  may  not  affect  the  teeth  directly,  yet 
they  induce  disease  of  the  surrounding  parts,  and 
thus  indirectly  exert  a  pernicious  influence  upon 
them. 

The  foregoing  remarks,  however,  refer  rather  to 
the  prevention  of  decay  than  to  its  treatment  after  it 
actually  exists.     Yet  they  are,  on  that  account,  none 


TREATMENT    OF   CARIES.  67 

the  less  important,  since  here,  as  elsewhere,  preven- 
tion is  better  than  remedy.  But  they  apply  to  such 
prevention  as  well  after  decay  has  commenced  as 
before,  if  the  ultimate  object  is  a  preservation  of  the 
teeth.  After  the  first  attack,  the  teeth  are  always 
more  vulnerable,  and  less  capable  of  resistance. 

When  decay  has  attacked  a  tooth,  the  treatment 
depends  upon  the  nature  and  extent  of  the  disease. 
Rapid  decay  requires  more  prompt  and  energetic 
treatment  than  that  of  slow  progress.  Remedies 
that  would  be  appropriate  and  efficient  in  the  one, 
would  be  quite  inapplicable  to  the  other.  The  per- 
sistence of  caries  is  not  always  in  proportion  to  its 
rate  of  progress.  We  sometimes  find  teeth  in  which 
the  decay  is  not  advancing  rapidly,  and  thence  are 
led  to  conclude  that  it  may  be  easily  arrested ;  the 
affected  part,  if  superficial,  is  removed,  and  the  den- 
tine finely  polished;  and  yet,  after  a  time,  decay 
again  attacks  the  tooth  at  the  same  point.  Or,  where 
the  caries  has  penetrated  the  tooth,  so  that  it  re- 
quires filling,  though  it  is  skillfully  filled,  and  the 
plug  and  tooth  carefully  polished,  yet  in  many  in- 
stances the  dentine  soon  softens  about  the  border  of 
the  plug. 

The  extent  of  the  decay  will  suggest  the  mode  of 
treatment.  Superficial  caries  on  some  parts  of  the 
teeth  may  be  remedied  and  removed  by  cutting  away 
the  portion  implicated  in  the  disease,  dressing  with  a 


68  CARIES   OF    THE   TEETH. 

fine  file,  polishing  with  Arkansas,  Scotch,  or  rotten 
stone  till  the  filemarks  disappear,  and  then  applying 
the  burnisher  very  thoroughly  to  the  entire  surface 
operated  upon.  Afterward,  the  most  careful  atten- 
tion to  cleanliness  is  requisite,  to  prevent  a  recur- 
rence of  the  attack.  This  treatment  is  applicable  to 
decay  upon  proximal  surfaces ;  but  in  the  depressions 
of  the  masticatory  or  buccal  surfaces  of  the  molars, 
and  on  the  labial  surfaces  of  the  front  teeth,  it  can 
not  be  employed. 

Sometimes  the  dentine,  at  points  where  it  is  ex- 
posed, gives  warning,  by  acute  sensitiveness,  of 
threatened  decomposition,  before  there  are  any  other 
indications  of  it,  thus  evidencing  the  presence  of 
some  very  irritating  agency  promotive  of  decay. 
Such  points  should  receive  prompt  and  strict  atten- 
tion, and  the  increased  sensitiveness  be  immediately 
subdued;  as  it  may  be,  by  the  use  of  some  prepara- 
tion that  will  counteract  the  exciting  influence — some 
dentifrice  or  lotion  containing  an  alkali;  or  a  rubbing 
of  the  sensitive  surface  with  a  smooth  steel  burnisher, 
will  in  many  cases  effect  this  object,  and  prevent  the 
development  of  decay. 

It  has  been  suggested  that  the  character  of  the 
caries  may  be  modified  by  the  local  application  of 
therapeutic  agents — that  the  rapid  decay  may  be 
changed  to  the  slow — and  this,  too,  without  regard 
to  the  attendant  circumstances,  such  as  the  condition 


TREATMENT    OF    CARIES.  69 

of  the  secretions  of  the  mouth,  the  causes  producing 
the  disease,  etc. ;  and  various  such  agents  have  been 
proposed.  It  is  held  that  by  an  application  of  the 
nitrate  of  silver,  the  white,  rapid  decay  being  changed 
to  that  of  a  dark  color,  becomes  of  less  rapid  progress. 
But  there  is  no  very  palpable  principle  on  which  this 
agent  can  be  supposed  to  operate  to  arrest  caries.  It 
is  generally  conceded  to  be  injurious  to  a  healthy 
tooth ;  how,  then,  it  becomes  beneficial  to  one 
decayed,  it  is  not  easy  to  perceive.  The  notion  may 
have  originated  in  the  fact  that,  after  the  application 
of  nitrate  of  silver,  the  cavity  turns  dark,  or  black ; 
and  this  color  being  naturally  associated  with  the 
slow  form  of  decay,  it  may  have  been  concluded  that 
it  might  be  thus  associated  by  artificial  means.  This 
conclusion,  however,  is  fallacious;  for  the  coloring 
matter  being  the  oxycl  of  silver  deposited  on  the 
walls  of  the  cavity,  is  wholly  foreign,  and  holds  no 
necessary  relation  to  the  kind  of  decay,  or  to  the 
agency  producing  it.  The  deposit  may  possibly  serve 
as  a  temporary  shield  to  the  dentine  beneath,  but 
only  temporary ;  whereas,  on  the  other  hand,  it  will 
be  remembered  that  nitric  acid  is  liberated  by  the 
decomposition  of  the  nitrate,  and  operates  destruc- 
tively upon  the  tooth-bone.  An  ethereal  solution  of 
the  terchlorid  of  gold  has  also  been  suggested  as  a 
preventive  application.  Its  operation  would  be  much 
the  same  as  that  of  the  nitrate  of  silver,  and  equally 


70  CARIES    OF    THE    TEETH. 

inefficient.  Preparations  to  neutralize  and  counteract 
the  effects  of  deleterious  agents  upon  the  teeth  have 
been  recommended  as  topical  applications.  These 
are  such  as  possess  alkaline  properties.  But  anything 
of  this  kind  would  require  frequent  application ;  in- 
deed, it  would  be  necessary  to  keep  the  affected  part 
constantly  under  its  influence,  as  long  as  the  sur- 
rounding conditions  continued  to  favor  decay. 

Though  nothing  of  this  kind  can  be  relied  upon 
permanently  to  arrest  caries,  }'et,  in  many  instances, 
much  benefit  is  to  be  derived  from  local  treatment. 
Alkaline  topical  applications  will,  in  many  cases, 
alleviate  the  most  acute  sensitiveness  of  the  dentine ; 
accomplishing  this,  no  doubt,  by  their  neutralizing 
influence  upon  the  irritating  agents.  Many  opera- 
tors employ  simply  the  bicarbonate  of  soda  for  this 
purpose,  with  the  happiest  results.  As  an  other  class 
of  topical  applications  to  check  or  modify  caries, 
those  have  been  suggested,  which  will  form  an  insol- 
uble compound  with  the  gelatinous  or  animal  portion 
of  the  tooth  ;  such  as  tannin  and  some  of  the  essen- 
tial oils.  The  only  effect  of  these,  however,  is,  to 
form  a  shield  or  protection  over  the  structure  be- 
neath :  there  is,  of  course,  no  change  effected  in  the 
conditions  or  agencies  which  produce  the  decay. 


CHAPTER  III. 

GENERAL   REMARKS   ON   FILLING. 

The  importance  and  value  of  the  operation  of  fill- 
ing are  obvious,  from  various  considerations.  It  is 
one  that  is  in  frequent  requisition.  It  is  the  only 
treatment  for  deepseated  caries  :  by  it,  the  disease  is 
arrested  and  the  lost  part  restored,  so  far,  at  least,  as 
it  can  be  by  a  foreign  substance.  There  is  no  mate- 
rial similar  to  that  destroyed — no  substance  possess- 
ing the  characteristics  of  the  lost  portion  of  the  tooth 
— with  which  to  effect  the  restoration.  Under  favor- 
able circumstances,  the  operation  of  filling  is  efficient 
in  arresting  caries  and  restoring  the  lost  portion  of 
the  tooth.  In  order,  however,  that  it  be  permanent 
in  its  character,  the  case  needs  to  be  attended  with 
favorable  conditions,  and  the  work  to  be  thoroughly 
done.  But,  two  similar  operations,  both  equally  well 
performed,  may  result  very  differently  as  to  ultimate 
success  in  preserving  the  teeth  to  which  they  may 
have  been  applied ;  the  one  effectually  preventing 
further  decay,  and  the  other  seeming  to  interpose  to 


72  GENERAL   REMARKS    ON    FILLING. 

it  but  little  obstacle.  Indeed,  the  probabilities  of 
such  success  in  different  operations,  equally  well  ac- 
complished, cannot  be  calculated,  without  consider- 
ing a  variety  of  circumstances,  such  as  differences  in 
constitutions,  in  states  of  health,  in  previous  and  sub- 
sequent habits. 

The  filling  of  the  teeth  is  predicated  upon  the  na- 
ture of  decay,  upon  the  fact  that  the  lost  portion  will 
not  be  restored  by  nature,  and  upon  the  fact  that 
caries  is  an  effect  of  external  causes,  and  not  of  any 
cause  within  the  tooth  itself.  If  the  cause  of  caries 
were  alone  within  the  tooth  itself,  then  filling  would 
not  be  its  rational  treatment.  The  organic  structure 
of  the  teeth  is  of  such  nature  that  no  change  will 
take  place  in  it,  independently  of  external  influences. 
Any  organ  possessing  sufficient  vitality  and  circula- 
tion to  be  susceptible  of  disease  and  decomposition, 
independently  of  external  influences,  possesses  recu- 
perative power  enough  to  restore  to  itself  a  lost  part; 
and  if  dentine  could  be  decomposed  without  external 
agents,  the  introduction  of  any  foreign  substance 
whatever  into  the  cavity,  would  certainly  not  arrest 
the  decay,  but  most  probably  would  accelerate  it.  If 
it  is  true  that  decay  of  the  teeth  ever  originates  in 
constitutional  causes,  then  the  treatment  should  be 
constitutional,  and  not  local. 

The  filling  of  teeth,  then,  is  based  upon  the  ina- 
bility even  of  healthy  dentine  to  resist  the  encroach- 


GENERAL    REMARKS    ON    FILLING.  73 

ment  of  decay.  As  preliminary  to  the  operation,  all 
the  circumstances,  both  direct  and  collateral,  should 
be  carefully  noted  in  every  case,  and  the  course  of 
treatment  should  conform  to  the  indications  thus  ob- 
served. The  constitution,  temperament,  and  health 
of  the  patient ;  the  peculiarities  of  the  teeth ;  their 
susceptibility  of  decay ;  their  present  condition,  and 
that  of  the  parts  about  them;  the  periosteum,  the 
gums,  the  mucous  membrane,  the  secretions  of  the 
mouth,  the  saliva,  and  the  mucus,  should  all  be 
closely  considered ;  for  only  on  a  correct  diagnosis 
can  a  proper  treatment  be  based.  Every  operation 
should  be  performed  as  completely  as,  under  the  cir- 
cumstances, is  possible.  Indeed,  every  step  in  the 
operation  should  be  perfect,  before  a  successive  one  is 
attempted.  All  the  instruments  employed  should  be 
unexceptionable  in  material,  form,  and  condition ; 
inferior  instruments  should  find  no  place  in  the  case 
of  the  dental  operator.  The  material  for  filling 
should  be  of  the  best  quality,  and  prepared  in  the 
best  possible  manner.  Not  that  material  for  filling 
should  be  prepared  in  only  one  way ;  for  some  mate- 
rials, gold  for  instance,  may  be  prepared  in  three  or 
four  different  forms,  each  perfect  in  its  kind,  and  effi- 
cient in  the  hands  of  the  expert  manipulator.  While 
with  instruments  and  material  all  in  the  most  perfect 
condition,  and  with  a  thorough  cognizance  and  appre- 
ciation of  all  the  attendant  circumstances,  our  most 


74  GENERAL   REMARKS   ON    FILLING. 

skilful  operators  barely  attain  success,  need  we  be 
astonished  that  the  man  ignorant  of  all  these  circum- 
stances, and  possessed  of  only  a  few  crude,  ill-condi- 
tioned instruments  and  materials,  the  nature  of 
which  he  does  not  understand,  fails  in  almost  every 
essay  ? 

Much  depends  on  therapeutic  treatment;  not,  in- 
deed, to  restore  parts  already  lost,  or  to  restore  to 
health  parts  much  diseased,  but  to  avert  a  tendency 
to  disease  in  parts  but  feebly  organized.  This  treat- 
ment may  be  either  constitutional  or  local,  or  both ; 
but  constitutional  when  there  is  indicated  any 
idiosyncrasy  favorable  to  decay.  If,  however,  the 
whole  difficulty  is  local,  topical  treatment  only  is  re- 
quired. What  the  special  treatment  should  be  in 
either  case  will  be  more  fully  considered  hereafter. 
Comparatively  little  can  be  accomplished  by  local  ap- 
plication to  the  substance  of  the  tooth ;  but  the  parts 
contiguous,  as  the  gums  and  the  mucous  membrane, 
may  be  thus  treated,  with  an  assurance  of  more 
signal  results. 

Though  in  the  teeth  nature  does  not  assist  to  re- 
store a  lost  portion,  as  in  those  parts  more  highly 
organized,  yet,  to  compensate  in  some  degree,  the  de- 
structive process  is  far  less  rapid  in  the  former  than 
in  the  latter.  The  general  surgeon  depends  much 
upon  nature  for  the  success  of  his  operations;  for, 
though  he  perforin  them  unskilfully,  yet  the  kind 


MATERIALS    FOR    FILLING.  75 

energy  of  nature  is  always  present  to  assist  him  ;  but 
in  this  specialty  the  practitioner  must  necessarily  de- 
pend more  upon  his  skill,  and  less  upon  the  curative 
efforts  of  nature. 

MATERIALS    FOR    FILLING. 

In  the  selection  of  materials  for  filling  teeth,  there 
are  some  important  considerations  that  should  be 
kept  constantly  in  view ;  the  first  and  principal  of 
which  is  to  choose  that  kind  which  will  protect  the 
tooth  from  further  decay — protect  the  affected  part 
against  the  influence  of  those  agencies  on  which  the 
disease  depends.  A  material  or  class  of  materials 
should  be  selected  that  would  not,  under  any  circum- 
stances, operate  either  as  a  local  or  a  constitutional 
injury.  There  are  several  properties  that  materials 
for  filling  teeth  should  possess,  one  of  the  most  im- 
portant of  which  is  indestructibility.  This  term  is 
technically  applicable  only  to  compounds;  but  we 
venture  here  to  expand  its  sense  so  as  to  indicate  by 
it  an  integrity  of  substance  as  well  in  a  simple  as  in  a 
compound  material ;  for,  considered  with  reference  to 
the  purpose  of  filling,  a  combination  of  the  simple 
with  another  substance,  is  as  much  a  destruction  as  is 
a  decomposition  of  the  compound.  Any  substance, 
whether  simple  or  compound,  that  will  not  maintain 
its  identity  and  integrity  when  subjected  to  any  con- 


76  GENERAL    REMARKS    ON    FILLING. 

ditions  of  the  mouth,  is  wholly  unfit  to  use  as  a  ma- 
terial for  filling.  If  compounds  are  employed,  they 
should  be  such  as  would  not  be  affected  by  the  secre- 
tions of  the  mouth,  by  its  temperature,  or  by  its  con- 
ditions. A  mere  mechanical  mixture  would  not  be 
an  appropriate  material ;  and  all  compounds  of  the 
metals,  so  far  as  we  are  familiar  with  them,  are  unfit 
for  this  purpose,  by  reason  of  the  facility  with  which 
they  are  destroyed  in  the  mouth. 

The  next  most  important  property  of  a  material 
for  filling,  is,  adaptability ;  by  which  is  meant  a  capa- 
bility of  being  wrrought  into  suitable  shapes  for  the 
purpose, — a  facility  of  being  applied  and  conformed 
to  the  parts  upon  which  it  is  to  be  placed.  There 
are  substances  that  would  be  entirely  indestructible 
in  the  mouth,  and  that  would  be  very  desirable  in 
other  respects  as  materials  for  filling,  yet  that  are 
altogether  worthless  for  this  purpose,  from  lack  of 
adaptability.  Quartz,  if  it  possessed  this  property, 
would  be  valuable  as  a  material;  but  as  yet  there 
has  been  discovered  no  method  of  preparing  it  in  an 
available  form.  On  the  other  hand,  many  things 
possess  the  property  of  adaptability,  that  are  lacking 
in  some  other  important  particulars. 

The  next  important  property  is,  hardness.  A 
material  may  possess  all  the  other  suitable  qualities, 
and  yet  be  too  soft.  A  material  should  be  hard 
enough  not  to  be  broken  by  any  pressure  or  friction 


MATERIALS    FOR    FILLING.  77 

liable  to  be  applied.  This  property  is  especially  desi- 
rable for  fillings  in  the  masticatory  surfaces  of  the 
molars  and  bicuspids.  It  would,  however,  be  admis- 
sible to  employ  a  softer  material  for  filling  cavities  in 
the  proximal  surfaces  of  the  teeth,  provided  it  per- 
fectly excluded  all  foreign  substances. 

Again,  a  material  should  be  as  nearly  as  possible  a 
nonconductor  of  heat,  particularly  for  filling  sensi- 
tive teeth,  or  those  liable  to  become  so  under  the 
influence  of  slight  causes.  Extreme  variations  of 
temperature  will,  in  most  instances,  aggravate  sensi- 
tiveness, and,  in  susceptible  cases,  produce  it ;  and,  if 
the  irritation  is  continued,  the  result  may  be  necrosis. 
Gold,  which  possesses  the  largest  number  of  desirable 
qualities  as  a  material  for  filling,  is  in  this  respect 
very  defective,  being  one  of  the  best  conductors  of 
heat.  To  obviate  this  defect,  some  nonconducting 
material  is  employed  between  the  gold  and  the  sensi- 
tive portion  of  the  tooth.  The  nerve  is  liable  to  be 
affected  by  sudden  and  extreme  changes  of  tempera- 
ture, transmitted  to  it  through  a  gold  plug. 

In  the  next  place,  a  material  should  be  susceptible 
of  being  welded,  or  united  into  a  solid  mass.  The 
permanency  of  an  operation  depends  very  much 
upon  this  quality.  A  filling  having  the  different 
pieces  which  compose  it  perfectly  consolidated,  will 
be  much  more  durable  than  if  effected  with  a  mate- 
rial in  which  this  cohesive  property  is  lacking,  can 


78  GENERAL    REMARKS    ON    FILLING. 

be  made  with  greater  facility,  and  will  be  better  and 
longer  retained;  and  mainly  because  such  a  filling 
cannot  be  destroyed  piecemeal.  Noncohesive  mate- 
rial is  retained  by  the  general  form  of  the  cavity, 
which  is  to  be  shaped  so  as  to  bind  all  the  pieces 
together,  and  thus  hold  them  in  place ;  but  a  sub- 
stance that  will  weld,  requires  only  two  or  three 
good  retaining  points,  angles,  or  pits,  properly  .situ- 
ated, in  order  to  be  firmly  and  permanently  fixed 
in  a  cavity  of  any  form. 

Color. — An  other  desirable  property  of  a  material 
for  filling,  is,  such  a  color  as  shall  best  harmonize 
with  that  of  the  teeth,  particularly  if  the}'  are  in 
front.  In  this  respect,  all  the  metals  are  objection- 
able; though  gold  is  probably  less  so  than  any  of  the 
others,  the  objection  to  this  being  not  so  much  in  its 
color  as  in  its  luster;  which  objection,  however,  may 
be  partially  obviated  by  the  kind  of  finish  given  to 
the  work.  In  teeth  of  certain  shades — semitrans- 
parent  bluish  white,  for  instance — gold,  for  exposed 
fillings,  is  very  objectionable;  indeed,  in  some  cases, 
as  unsightly  as  would  be  an  entire  absence  of  the 
tooth ;  and,  in  such  instances,  the  darker  metals 
would  of  course  appear  much  worse.  For  such  teeth, 
some  mineral  substances  would  be  most  desirable. 

Most  of  the  materials  employed  for  filling  are 
metallic;  only  a  few  nonmetallic  substances  have 
been  used,  and  these  rather  by  way  of  experiment, 


MATERIALS    FOR    FILLING.  79 

than  with  any  hope  of  permanent  success.  Of  the 
metals,  gold  possesses  more  of  the  indispensable  pro- 
perties than  any  other ;  but  the  following  have  all 
been  used  for  filling :  lead,  tin,  silver,  platinum,  gold, 
and  amalgam.  In  the  preparation  of  the  latter, 
gold,  silver,  platinum,  tin,  bismuth,  antimony,  cad- 
mium, zinc,  and  mercury,  have  been  employed. 

Lead. — This  metal,  in  the  early  history  of  the  pro- 
fession, was  used  to  some  extent  for  filling,  though  it 
possesses  but  few  of  the  requisites  for  that  purpose. 
The  principal  quality  which  recommended  it,  is  its 
adaptability ;  but  it  is  quite  too  soft  for  permanent 
fillings  in  the  masticatory  surfaces  of  the  molars.  It 
is  easily  wrought  into  foil  and  welded  into  mass  in 
the  cavity,  but  is  rapidly  worn  down  by  mastication, 
and  its  integrity  readily  impaired  by  the  influence  of 
peculiar  conditions  of  the  mouth  ;  much  more  readily, 
indeed,  than  that  of  tin  or  silver.  Acetic  and  other 
acids  act  upon  it  with  considerable  energy  in  the 
mouth,  being  there  subjected  to  both  heat  and  moist- 
ure. By  exposure  to  air  and  moisture,  it  is  soon 
coated  with  carbonate  or  protoxyd  of  lead  ;  and  this 
change  is  effected  much  more  readily  in  the  mouth. 
Lead  is  also  objectionable  in  color — especially  for  fill- 
ings in  the  anterior  teeth — it  being  darker  than  the 
other  metals  employed  for  the  purpose.  It  is,  how- 
ever, a  less  perfect  conductor  of  heat  than  some 
others  that  are  in  far  more  extensive  use. 


80  GENERAL    REMARKS    ON    FILLING. 

Tin. — This  metal  has  been,  and  is  even  yet,  much 
employed  as  a  material  for  filling.  It  is  easily 
wrought  into  foil,  and  in  that  condition  is  readily 
adapted  to  the  purpose,  by  reason  of  its  softness  and 
pliability.  Fillings  can  be  made  with  it  in  all  cases 
in  which  nonadhesive  gold  foil  can  be  used,  to  much 
of  which,  indeed,  it  can,  by  skillful  manipulation,  be 
made  superior  in  adhesive  property.  Its  quality, 
however,  is  greatly  dependent  on  the  manner  of  its 
manufacture.  It  is  harder  than  lead,  and  in  many 
cases  hard  enough  for  permanent  fillings :  we  have 
known  it  retained  in  crown  cavities  of  the  molars, 
effectually  preserving  the  teeth,  for  fifteen  years.  In 
favorable  conditions  of  the  mouth,  it  is  not  materially 
changed,  not  oxydizing  easily,  and  not  readily  uniting 
with  any  substances  liable  to  be  brought  in  contact 
with  it.  But  in  an  unhealthy  mouth,  with  the  secre- 
tions in  an  abnormal  condition,  and  the  teeth 
neglected,  tin  fillings  are  very  rapidly  destroyed. 
Such  a  change  may  take  place  in  the  mouth,  as  will 
in  a  little  time  destroy  tin  fillings  that  had  long 
remained  in  good  preservation  ;  and  hence  this  mate- 
rial is  not  entirely  reliable  in  any  case,  since  such 
change  may  at  any  time  occur.  Some  cases  seem- 
ingly favorable  to  its  use,  are  found,  on  examination, 
to  be  otherwise ;  and  in  almost  any  mouth  in  which 
there  is  a  large  proportion  of  mucus  secreted,  it  can 
not  be    depended    upon  for   permanency.     Its  color 


MATERIALS    FOR    FILLING.  81 

renders  it  unfit  for  the  anterior  teeth.  It  is  a  less 
perfect  conductor  of  heat  than  gold ;  on  which  ac- 
count it  is  frequently  employed  where  the  latter 
metal  can  not  be.  It  should  not  be  used  in  a  tooth  in 
which  there  is  an  other  metal ;  notwithstanding  some 
economical  dentists  do  sometimes  use  it  to  fill  the 
interior  of  large  cavities,  placing  upon  it  a  covering 
of  gold.  This  method  is  objectionable  in  two  parti- 
culars :  first,  the  tin  is  softer  than  the  gold,  and 
under  much  pressure  yields  beneath  it,  so  as  to 
destroy  the  integrity  of  the  filling ;  and  second,  when 
the  fluids  of  the  mouth  come  in  contact  with  the  two 
metals,  a  chemical  action  is  induced,  by  which  the 
tin  is  rapidly  oxydized.  It  is  for  this  reason  that  no 
two  metals  should  be  applied  to  the  same  tooth ;  as, 
for  instance,  tin  for  filling  a  tooth  round  which  there  is 
a  gold  clasp,  or  in  contact  with  which  is  a  gold  plate. 
Finally,  the  use  of  this  material  should  be  deter- 
mined not  only  by  all  these  circumstances,  but  also 
by  the  constitutional  predisposition  of  the  patient, 
and  the  character  of  the  teeth,  which  should  be  dense 
and  well  organized,  in  order  to  render  it  at  all  admis- 
sible. 

Silver. — This  metal  was  formerly  in  more  extens- 
ive use  as  a  material  for  filling,  than  it  is  at  present. 
It  is  not,  for  this  purpose,  superior  to  tin  in  any  par- 
ticular, except  in  being  somewhat  harder;  and  in 
some    particulars   it  is    inferior,  being   quite   as   de- 


82  GENERAL    REMARKS    OX    FILLING. 

structible  in  the  month ;  more  easily  affected  by  cer- 
tain agents,  such  as  nitric  acid,  nascent  chlorine,  etc.; 
less  pliable  and  less  adaptable;  more  difficult  to  work 
into  foil;  not  so  readily  formed  into  fillings;  and  pos- 
sessed of  much  less  cohesiveness,  being  almost  un- 
weldable  by  the  ordinary  method  of  manipulation. 
Silver  is  a  better  conductor  than  tin,  and  would 
therefore  in  some  cases  be  more  objectionable.  The 
saliva  is  often  in  such  a  condition  as  to  act  upon  it 
with  great  energy  and  rapidity.  Its  color,  too,  is  ob- 
jectionable. With  these  disadvantages,  its  use  has 
very  properly  been  wholly  abandoned. 

Platinum. — This  metal  has  been  but  little  used  for 
the  purpose  of  filling;  though  it  possesses  some  of 
the  requisite  qualities  in  a  very  high  degree ;  as,  for 
instance,  indestructibility,  in  which  property  it  is  su- 
perior to  gold.  In  some  other  respects,  however,  it 
is  very  deficient;  it  has  not  as  yet  been  wrought  into 
any  form  in  which  it  can  be  welded  with  facility ;  it 
is  difficult  to  work  into  foil ;  and,  when  it  is  put  into 
this  form,  it  possesses  a  stiffness  and  harshness  that 
render  its  adaptation  and  condensation  almost  im- 
practicable. It  is  more  on  this  account,  perhaps, 
than  on  any  other,  that  it  has  been  so  little  employed 
for  the  purpose  of  filling.  It  has  also  less  adhesive- 
ness than  gold,  and  much  sooner  parts  with  this  prop- 
erty. Slight  crumpling  or  bending  serves  to  stiffen 
it   so  as   to  destroy  its  applicability.     Good   fillings 


MATERIALS    FOR    FILLING.  88 

may  be  made  of  well  prepared  platinum  sponge,  re- 
cently annealed.  It  requires  skillful  manipulation, 
however ;  for  the  least  moisture  destroys  its  cohesive 
property  entirely.  It  is  quite  as  good  a  conductor  of 
heat  as  gold,  and  on  this  account  equally  objectiona- 
ble. In  the  respect  of  color,  too,  it  is  undesirable. 
Platinum  should  never  be  placed  in  close  proximity 
to  tin  fillings,  or  to  gold  plate  or  clasps  of  few  carats. 
It  is  not  now,  however,  used  in  filling  at  all,  except 
for  experiments. 

Gold. — Of  all  the  metals  that  have  as  yet  been 
used  for  filling  teeth,  gold  possesses  more  of  the 
requisite  properties  than  any  other.  It  is  more  inde- 
structible than  any  other,  and  sufficiently  so  for  all 
practical  purposes.  Twenty-carat  gold  is  very  sel- 
dom affected  by  any  agencies  with  which  it  is 
brought  in  contact  in  the  mouth ;  pure  gold,  never. 
In  the  filling  of  teeth,  there  are  two  objects  to  be 
aimed  at :  one,  a  sufficient  hardness  to  withstand  the 
wear  of  mastication ;  the  other,  a  thorough  protection 
to  the  cavity  against  all  foreign  substances.  For  the 
attainment  of  the  first  of  these,  gold  is  not  all  that 
could  be  desired;  yet  it  is,  perhaps,  as  efficient  in  this 
respect  as  any  other  metal  that  can  be  employed.  But 
the  second  object  gold  accomplishes  perfectly;  that  is,, 
so  long  as  the  filling  maintains  its  integrity;  after  it 
has  partially  worn  out,  it  thus  far  fails,  of  course.  In 
adaptability,  too,  gold  is  superior  to  any  other  metal. 


84  GENERAL   REMARKS    ON    FILLING. 

It  can  be  elaborated  into  a  variety  of  forms,  with  any 
of  which  very  good  fillings  can  be  made.  It  can  be 
perfectly  conformed  to  any  shape  of  surface,  however 
irregular.  A  tooth  that  can  be  filled  at  all,  can  be 
filled  with  gold.  This  assertion  was  made  a  number 
of  years  ago ;  and  if  it  was  true  then,  it  is  much  more 
true  now ;  for  then  the  adhesive  property  of  gold  was 
not  employed  at  all,  or  even  recognized  as  available ; 
but  now,  this  property  has  been  rendered  efficient  and 
practicable.  Then,  our  best  operators  did  not  aim  to 
unite  the  different  portions  of  gold  of  which  the  fill- 
ings were  composed.  The  idea  that  such  consolida- 
tion could  be  effected,  seemed  never  to  have  entered 
their  minds.  Indeed,  with  the  instruments  and  the 
method  of  manipulation  then  employed,  this  adhesive 
property  could  not  have  been  made  available ;  but  as 
it  came  to  be  recognized,  the  instruments  and  the 
manipulation  were  adapted  to  the  purpose.  For- 
merly, an  ordinary  gold  plug  when  removed  from  a 
cavity,  would  be  separated  into  as  many  pieces  as 
originally  composed  it ;  but  now,  when  adhesive  gold 
is  skillfully  used,  the  mass  composing  a  filling  can  not 
be  divided  into  its  original  parts,  but  may  be  wrought 
into  plate,  wire,  or  foil.  Nonadhesive  gold — the 
modification  in  which,  till  recently,  it  was  always 
employed — would  not  weld,  even  under  great  press- 
ure ;  but,  in  the  mode  in  which  it  is  now  prepared, 
it  will  weld  readily  and  thoroughly.     There  are  cer- 


MATERIALS    FOR    FILLING.  85 

tain  requisites  essential  to  this  welding  property  of 
gold :  if  it  is  in  the  form  of  foil,  it  must  not  present 
a  smooth,  planished  surface ;  it  must  be  annealed 
after  hammering,  in  order  that  its  ultimate  particles 
may  be  in  the  best  condition  for  cohering;  it  must 
be  entirely  free  from  all  deposits  of  foreign  substance; 
and  it  must  be  kept  from  exposure  to  the  atmos- 
phere. 

Gold  is  a  good  conductor  of  heat;  and  this  is  the 
chief  objection  to  it  as  a  material  for  filling.  As  to 
sensitive  teeth,  this  is  a  very  serious  objection,  in 
some  cases  necessitating  the  employment  of  non- 
conducting materials  with  it,  and  in  others  preclu- 
ding its  use  altogether.  The  color  of  gold,  however, 
is  seldom  an  objection  to  its  use ;  though  it  some- 
times renders  it  unsuitable  for  fillings  in  the  front 
teeth.  But  this  objection  has  been  already  adverted 
to. 

Various  Preparations  of  Gold. — And  first,  of  the 
manufacture  of  gold  foil.  For  this  purpose,  pure 
gold  is  used ;  for  procuring  which,  various  methods 
are  employed.  But  the  most  common  of  these  are 
insufficient  for  the  production  of  gold  absolutely  pure. 
It  is,  however,  deemed  irrelevant  here  to  detail  the 
process  by  which  this  end  is  attained :  it  is  enough  to 
premise  that,  for  the  manufacture  of  the  best  quality 
of  foil,  perfectly  pure  gold  is  indispensable.  The 
gold  is  cast  into  an  ingot  about  an  inch  wide,  which 


86  GENERAL    REMARKS    ON    FILLING. 

is  placed  between  a  pair  of  rollers,  and  rolled  down 
as  thin  as  practicable,  the  piece,  while  rolling,  being 
frequently  annealed.  It  is  then  cut  into  squares, 
which  are  inserted  with  wooden  pliers  between  vel- 
lum leaves,  a  hundred  and  sixty  or  seventy  in  a 
pack.  Over  this  pack  two  pockets  are  drawn,  in- 
closing it  completely.  The  pack  then,  while  it  is 
carefully  annealed,  is  hammered  on  a  marble  block, 
with  a  hammer  weighing  twelve  or  sixteen  pounds, 
till  the  leaves  are  spread  out  to  the  full  extent  of  the 
pack.  Much  experience  and  skill  are  requisite  to 
the  proper  accomplishment  of  this  part  of  the  work : 
by  a  single  unskillful  stroke  of  the  hammer,  a  whole 
pack  might  be  spoiled. 

Gold  foil  is  numbered  according  to  the  grains  con- 
tained in  each  leaf,  ranging  from  2  to  30.  The  most 
common  numbers  are,  2,  3,  4,  5,  6,  8,  10,  15,  20,  and 
30,  the  smaller,  from  2  to  6,  being  in  most  frequent 
use.  It  has  heretofore  been  a  desideratum  to  obtain 
gold  foil  perfectly  uniform ;  but  some  few  manufac- 
turers now  seem  to  have  attained  this  perfection. 

Crystal  Gold. — This  form  of  gold  was  introduced  to 
the  profession  about  five  years  ago.  Some  experi- 
ments in  this  direction,  indeed,  had  been  made  as 
early  as  1825,  by  C.  Ash,  of  London,  and  again  in 
1850,  by  Dr.  S.  A.  Main,  of  New  York.  Their  prep- 
arations, however,  were  simply  precipitates,  and 
nothing   more.     But  in  1853,  Dr.  A.  J.   Watts,  of 


MATERIALS    FOR    FILLING.  87 

Utica,  New  York,  obtained  letters  patent  for  his  prep- 
aration of  gold  for  filling  teeth.  This  preparation 
was  at  first  denominated  sponge  gold,  but  after  some 
modification,  received  its  present  name.  There  are 
numerous  formulas  by  which  preparations  of  crystal 
gold  may  be  made ;  but  so  far  as  we  are  acquainted 
with  them,  they  are  all  embraced  in  two  general 
methods :  the  one,  to  obtain  simply  a  precipitate  of 
the  metal,  adaptable  to  the  filling  of  the  teeth ;  and 
the  other,  to  combine  this  precipitate  with  mercury, 
and  obtain  a  definite  crystallization.  For  the  prepa- 
ration of  the  sponge  or  crystal  gold,  the  absolutely 
pure  metal  is  required.  This  is  dissolved  in  nitro- 
muriatic  acid,  the  gold  being  added  till  the  solution 
is  saturated.  Various  materials  may  be  used  to  pre- 
cipitate it,  the  most  common  of  which  are  sulphate  of 
iron  and  oxalic  acid,  the  latter  on  some  accounts 
being  preferable.  The  character  of  the  precipitate 
will  be  determined,  in  a  great  degree,  by  the  manner 
in  which  the  precipitant  is  added  :  if  slowly,  the  pre- 
cipitate will  be  more  fibrous,  or  structural. 

A  preparation  may  be  made  by  introducing  the 
precipitant  gradually,  and  then  carefully  washing  the 
precipitate,  and  heating  almost  to  redness.  For  per- 
fect crystallization  of  the  gold,  combine  the  precipi- 
tate with  from  six  to  twelve  times  its  weight  of  pure 
mercury,  let  it  stand  a  short  time,  subject  to  a  gentle 
heat,  and  then  remove  the  mercury  with  dilute  nitric 


88  GENERAL    REMARKS    ON    FILLING. 

acid.  Afterward  wash  the  nitrate  of  mercury  from 
the  gold ;  place  the  latter  upon  a  slide,  and  bring  it  up 
to  a  full  red  heat  in  a  muffle,  and  the  gold  is  then  in 
a  condition  to  be  used  for  filling.  This  is  about  the 
formula  on  which  a  patent  was  granted  to  A.  J. 
Watts.  The  preparation  possesses  some  advantages 
over  gold  foil :  it  is  as  readily  introduced ;  it  is  more 
capable  of  thorough  consolidation;  it  has,  besides  the 
cohesiveness  of  foil,  the  additional  property  of  inter- 
lacing its  crystals  one  with  another,  by  which  prop- 
erty, even  without  cohesion,  the  pieces  of  a  filling 
can  be  firmly  united ;  and  it  takes  a  better  hold 
upon  the  walls  of  the  cavity,  to  which  it  presents 
edges  and  ends,  so  as  to  be  more  thoroughly  adapted 
and  fastened. 

Amalgam. — By  this  term  are  designated  all  those 
preparations  formed  by  a  combination  of  mercury 
with  various  other  metals ;  most  frequently  with  sil- 
ver and  tin,  but  occasionally  with  gold,  platinum, 
bismuth,  cadmium,  zinc,  and  lead.  The  several  form- 
ulas for  amalgam  need  not  here  be  specified.  The 
kind  most  in  use  is  prepared  by  melting  together  and 
carefully  mixing  pure  tin  and  silver,  filing  this  mixt- 
ure, when  cooled,  into  dust,  combining  the  latter 
with  mercury  in  sufficient  proportion  to  give  the 
requisite  plasticity,  and  then  thoroughly  washing  the 
whole  in  alcohol  or  boiling  water,  to  eliminate  the 
oxyds  formed  by  the  combination  of  the  metals.     If 


MATERIALS    FOR    FILLING.  89 

there  is  a  redundance  of  mercury,  it  may  be  removed 
by  pressing  the  paste  in  a  piece  of  chamois  skin. 
This  preparation  may  in  some  cases  be  used  for 
filling  with  considerable  success;  but  in  no  case  can 
it  be  relied  upon  as  a  durable  material,  its  destructi- 
bility  being  no  less  than  that  of  tin  or  silver  in  any 
circumstances,  and  being  greater  where  all  the  mer- 
cury is  not  removed  from  the  surface  of  the  filling, 
and  the  surface  not  burnished  down  solid  and 
smooth.  Mercury  oxydates  with  considerable  rapid- 
ity when  exposed  to  air  and  moisture,  and  with  in- 
creased energy,  under  the  influence  of  heat,  especially 
when  some  acid  is  present.  This  facility  of  oxyda- 
tion  is  still  increased  when  other  metals  are  com- 
bined with  the  mercury.  Oxydation  of  such  fillings 
will  in  some  cases  be  confined  to  the  surface,  wherever 
there  is  contact  of  moisture;  in  others,  it  will  per- 
vade the  whole  mass,  rendering  it  black  and  spongy 
throughout. 

Amalgam  fillings,  in  a  short  time  after  their  inser- 
tion, undergo  a  hardening  process,  caused  mainly  by 
evaporation  of  the  mercury.  The  consequence  is, 
either  that  the  mass  becomes  porous,  or  that  it  con- 
tracts; the  former,  doubtless,  in  cases  where  the 
oxydation  blackens  through,  and  the  latter,  where  it  is 
confined  to  the  surface.  When  a  plug  is  in  either  of 
these  conditions,  the  preservation  of  the  tooth  is  very 
uncertain.     On  removing  an  ordinary  amalgam  plug 


90  GENERAL    REMARKS    ON    FILLING. 

that  has  been  worn  for  some  time,  its  entire  surface 
will  generally  be  found  oxydized :  and  a  tooth  filled 
with  this  material  generally  becomes  blackened,  and 
its  appearance  ruined. 

To  such  objections  against  this  material,  an  other 
is  to  be  added  in  cases  in  which  there  are  fillings  or 
plate  of  platinum  or  gold :  galvanic  action  will  be 
established,  in  a  degree  proportionate  to  the  proxim- 
ity of  the  metals  and  the  condition  of  the  secre- 
tions. This  may  occasion  much  mischief.  Some 
constitutions  are  very  susceptible  of  the  influence  of 
mercury ;  and  a  gradual  decomposition  of  several 
amalgam  fillings  in  the  mouth,  may  seriously  impair 
the  general  health.  Therefore,  before  this  material  is 
ever  employed,  the  health,  temperament,  habits  of  the 
patient,  should  be  carefully  noted ;  for  these  and  other 
circumstances  may  often  indicate  its  inadmissibility. 

So  great  and  so  numerous  are  the  objections  to  this 
material,  that  it  is  but  little  used  by  reliable  opera- 
tors. Its  adaptability  is  the  main  property  on  which 
are  based  the  arguments  in  its  favor :  it  is  easily 
applied,  and  consolidates  with  considerable  hardness. 
It  is  affirmed,  also,  that  teeth  which  cannot  be  saved 
with  anything  else,  may  be  filled  with  this,  and  made 
valuable.  This,  however,  is  not  true  since  the  em- 
ployment of  the  adhesive  property  of  gold ;  which 
property  renders  this  metal  equal  in  adaptability  to 
amalgam. 


MATERIALS    FOR   FILLING.  91 

Nonmetallic  Materials. — Of  the  nonmetallic  mate- 
rials experimented  with  for  filling,  there  are  not 
many  worthy  of  any  particular  consideration.  In- 
deed, gutta  perch  a  and  its  preparations  constitute  the 
chief  nonmetallic  substances  now  used  for  this  pur- 
pose, though  some  others  have  been  employed. 
Gutta  percha  is  useful  for  temporary  fillings,  and, 
under  ordinary  circumstances,  sufficiently  durable. 
It  is  valuable  for  filling  those  teeth  which  it  may  be 
desirable  to  retain  only  a  short  time,  or  those  in 
which  it  may  be  necessary  temporarily  to  protect  a 
sensitive  part  against  the  influence  of  irritating 
agents,  in  order  to  restore  it  to  health.  Gutta 
percha  is  not  readily  decomposed  by  the  fluids  of  the 
mouth,  when  they  are  in  a  healthy  condition.  In 
some  instances,  we  have  known  it  worn  in  the 
mouth  for  years,  with  but  little  change.  But  in 
cavities  on  the  grinding  surfaces  of  the  molars  and 
bicuspids,  it  will  not  withstand  the  wear  of  mastica- 
tion a  great  while,  though  long  enough  in  most  cases 
to  subserve  the  purposes  of  a  temporary  filling.  It 
possesses  great  adaptability  :  by  simply  being  warmed 
over  a  spirit-lamp  or  in  boiling  water,  it  becomes 
plastic,  and  is  with  great  facility  introduced  and  con- 
formed to  the  cavity.  It  may  be  applied  also  in 
solution,  being  dissolved  in  chloroform  till  it  ap- 
proaches a  pasty  consistence,  then  absorbed  in  a 
pledget  of  cotton,   and  introduced  into  the  cavity; 


92  GENERAL    REMARKS    ON    FILLING. 

where  the  chloroform,  evaporating,  leaves  the  gutta 
percha  as  a  filling.  The  only  objection  to  this 
method  is,  the  contraction  consequent  on  the  evapo- 
ration of  the  chloroform.  Another  property  that 
renders  this  substance  highly  valuable,  is,  its  non- 
conduction  of  heat,  it  being  in  this  respect  as  nearly 
perfect  as  any  other  material  employed. 

A  preparation  of  gutta  percha  with  mineral  sub- 
stances, known  as  HUTs  stopping,  has,  for  the  last 
four  years,  been  extensively  used  for  temporary  fill- 
ings ;  indeed,  it  has  superseded  simple  gutta  percha 
almost  entirely.  The  aim  of  this  preparation  was  to 
obviate  two  or  three  objections  to  pure  gutta  percha; 
as,  its  contractibility  in  the  cavity,  its  softness,  and  its 
color.  The  composition  of  HUTs  stopping  is  as  fol- 
lows :  With  pure  gutta  percha  in  a  plastic  state,  are 
mixed  quicklime  two  parts,  and  quartz  and  feldspar 
one  part  each,  which  latter  are  reduced  to  an  impal- 
pable powder,  and  kneaded  into  the  mass  as  long  as 
it  will  receive  them  without  becoming  brittle.  Such 
is  the  formula  given  by  the  inventor  of  this  prepara- 
tion ;  though  it  is  presumed  that  one  of  these  mate- 
rials alone,  namely,  pulverized  quartz,  would  be 
found  entirely  sufficient,  since  it  is  capable,  by  itself, 
of  quite  as  much  as  is  attained  by  all  together.  The 
addition  of  gold  or  platinum  filings  has  been  recom- 
mended ;  but  no  advantage  is  thus  gained.  It  was  at 
first  claimed  for  this  material  that  it  would  serve  for 


MATERIALS    FOR    FILLING.  93 

permanent  fillings ;  but  it  was  soon  demonstrated  in- 
sufficient. It  was  supposed,  also,  that  it  might  be 
employed  for  partial  fillings  in  large  cavities,  which 
could  be  completed  with  gold ;  but  for  this,  too,  it 
was  found  impracticable,  since  it  did  not  make  a  suf- 
ficiently firm  foundation. 

This  preparation  is  applied  in  the  same  manner  as 
simple  gutta  percha,  being  warmed  on  a  porcelain  or 
metal  slab  over  a  spirit-lamp  till  sufficiently  soft,  and 
then  packed  into  the  cavity.  It  cannot  be  employed 
in  the  form  of  solution,  nor  should  it  be  softened  in 
boiling  water.  It  may  be  conveniently  prepared  by 
dissolving  the  gutta  percha  in  chloroform  to  almost 
a  pasty  consistence,  then  adding  the  mineral  sub- 
stances, and  putting  it  into  a  vessel  suitable  for  the 
evaporation  of  the  chloroform.  It  should  be  made  so 
thick,  that  the  silex  would  not  fall  to  the  bottom. 
When  HUTs  stopping  or  gutta  percha  is  used,  as  soon 
as  the  cavity  is  filled,  an  instrument  with  the  end 
nearly  as  large  as  the  orifice  of  the  cavit\7,  should  be 
placed  upon  the  filling,  and  retained  there  with  con- 
siderable pressure  till  the  mass  is  cool.  We  as  yet 
know  of  nothing  better  for  temporary  fillings  than 
this  preparation  of  gutta  percha. 


CHAPTER  IV. 

INSTRUMENTS   FOR   FILLING. 

In  describing  the  instruments  for  filling  teeth,  it 
will  be  convenient  to  take  them  somewhat  in  the 
order  in  which  they  are  employed  in  ordinary  prac- 
tice ;  first  referring  to  those  which  are  used  for  cut- 
ting away  portions  of  the  teeth,  for  the  purpose  of 
separating  them,  and  for  dressing  off  the  borders  of 
cavities;  then  to  those  for  removing  decay  and  form- 
ing the  cavities ;  and  finally  to  those  for  introducing, 
consolidating,  and  finishing  fillings.  The  first,  then, 
that  claim  our  attention,  are  the 

HEAVY    CUTTING-INSTRUMENTS. 

These  are  of  the  thick  chisel  shape.  They  should 
be  of  good  steel,  well  wrought,  and  thoroughly  tem- 
pered. Every  step  in  the  process  of  their  manufac- 
ture should  be  most  perfectly  executed,  so  as  to  in- 
sure an  edge  that  will  cut  not  only  dentine,  but  also 
enamel,  which  is  the  hardest  animal  substance.  Va- 
rious sizes  of  the  straight  chisel  form  are  required. 


HEAVY    CUTTING-INSTRUMENTS. 


95 


In  all  cases  they  should  be  as  thick  as  possible,  with- 
out being  thus  impaired  in  their  efficiency ;  so  firm 
that  there  may  be  no  springing  or  tremulous  motion 
under  the  pressure  they  are  required  to  sustain.  For 
separating  front  teeth,  however,  they  must  be  thin 
enough  to  pass  readily  into  the  intended  space,  and 
about  one  fourth  of  an  inch  wide  at  the  edge.      (See 

Fie.  2. 


Fig.  2.)  But,  for  separating  bicuspids  and  molars, 
the  instruments  should  be  thicker  and  broader;  as 
thick,  indeed,  as  the  respective  intervals  will  admit. 

Fin.  3. 


(Fig.  3.)     In  some  cases,  they  should  have  the  edge 
oblique,  as  in  Fig.  4. 

It   is    seldom   that    these    instruments    need    any 


Fie.  4. 


curve.     The  straight  form  is  the  best,  unless,  as  it 
rarely  happens,  the  point  to  be  operated  upon  can  not 


96 


INSTRUMENTS    FOR    FILLING. 


be  reached  efficiently  with  it ;  as,  for  instance,  in  a 
small  mouth,  a  slight  anterior  curve  will  be  required 
in  the  shaft  of  the  instrument,  to  facilitate  its  ap- 
proach to  the  front  proximal  surface  of  a  second  or  a 
third  molar.      (Fig.  5.)     A  heavy  instrument,  with  a 


Fig.  5. 


sharp  point  and  a  lateral  curve,  is  often  efficient  in 
opening  up  cavities  and  cutting  down  strong  projec- 
tions of  enamel.     (Fig.  6.)     This  class  of  instruments 


Ficr.  6. 


we  consider  as  valuable  as  any  other  in  our  case. 
Every  operator  should  have  at  hand  a  sufficient  va- 
riety to  meet  every  demand. 


DRILLS. 


Bar  Drills. — Of  this  indispensable  class  of  instru- 
ments there  are  various  forms.  They  should  be 
manufactured  of  the  best  steel,  and  wrought  with  the 


greatest  care. 


After  having  been  forged  as  near  the 


DRILLS. 


97 


proper  size  as  possible,  the  bulb  is  shaped  by  dressing 
with  a  fine  file,  or  by  turning  in  a  lathe;  those 
made  by  the  latter  method  being  superior,  and  cut- 
ting much  more  smoothly;  they  do  not  catch  and  jar 
as  do  those  of  less  regular  form.  After  the  bulb  is 
formed,  it  is  usually  cut  with  a  sharp-edged  file. 


Fig.  r. 


Of  these  drills,  Fig.  7  represents  a  bur  of  a  spher- 
ical form.     Fig.  8  is  cone-shaped,  which  may  have 


Fig.  8. 


various  degrees  of  bevel,  terminating  in  a  sharp 
point.  Fig.  9  is  of  a  cylindrical  form,  cut  upon 
the  sides    and   end.     Fisr.  10   is   in   the  form   of  a 


Fig.  9. 


wheel,   cut  upon   the  edge   only,   or  upon  both  the 
edge  and  the  end.     The  cutting  upon  all  of  these 


98  INSTRUMENTS   FOR   FILLING. 

should  be  very  regular  and  uniform.  This  should 
be  made  by  machinery,  though  it  is  usually  done  by 
hand.      Of    these    instruments,    there   should   be   a 

Pier.  10. 


variety  in  size,  the  smallest  considerably  less  than 
the  smallest  cavity  the  dentist  ever  attempts  to  fill — 
that  is,  about  one  thirtysecond  of  an  inch  in  diam- 
eter, and  the  largest  about  one  fifth  of  an  inch. 
Inclusive  of  these  extremes,  there  should  be  about 
fifteen  sizes  of  each  particular  form.  These  instru- 
ments are  used  for  opening  cavities.  With  them  a 
more  regular  and  perfect  orifice  is  made  in  small  and 
medium-sized  cavities,  than  by  any  other  method. 
They  are  also  used. to  some  extent  for  forming  the 
cavities,  and  even  sometimes,  in  large  cavities,  for 
making  retaining-points  for  a  filling. 

Common  Drills. — Of  an  other  kind  of  drills,  Fig. 
11  represents  one  with  a  square  point,  beveled  from 

Fie.  11. 


both  sides,  measuring  from  a  half  to  a  whole  line  in 
length,  and  attached  to  a  small  round  shaft.  The 
edges  of  the  drills  should  be  very  hard,  so  that  they 


DRILLS. 


99 


may  cut  with  the   greatest  celerity.     Of  this  kind, 
there   should   be   about   ten  sizes,   ranging  in  width 
from  No.  15  to  No.  25  of  Stub's  gauge.     These  are 
used  mainly  for  forming  retaining-points  in  cavities. 
Fig.  12    is    the   spear-shaped   drill,   the   edges   of 

Fig.  12. 


which  are  formed  by  dressing  from  both  sides ;  or,  it 
may  be,  from  only  one,  in  which  case  it  will  cut  only 
when  rotating  one  way.  This  shape  is  employed 
principally  for  drilling  out  fangs  for  filling  or  receiv- 
ing pivot  teeth. 

The  burs  and  drills  may  be  made  of  pieces  of  wire 
one  and  a  half  inches  long,  and  fitted  to  a  socket- 
handle  that  will  accommodate  a  large  number ;  or  of 
a  continuous  piece  of  large  wire.  The  latter  is  the 
preferable  method,  since  much  time  is  consumed  in 
changing  them  in  sockets.  The  handles  should  be 
made  with  six  or  eight  sides,  and  cut  on  each  alter- 
nate side.  In  the  use  of  these  instruments,  the 
socket-ring  is  almost  indispensable.  This  is  an  open 
ring  for  the  middle  or  the  index  finger,  with  a  socket 
attached,  in  which  rests  the  end  of  the  handle  of  the 


100 


INSTRUMENTS    FOR    FILLING. 


instrument.  (Fig.  13.)   The  drill  is  rotated  commonly 
with  the  thumb  and  ringers. 


Fisr.  13. 


Drill-stocks  of  various  forms  have  been  invented, 
with  the  view  of  increasing  the  motion  of  the  drill, 
of  augmenting  its  power,  or,  especially,  of  bringing  it 
to  bear  upon  points  inaccessible  to  the  straight  in- 
strument. Some  of  these  stocks  are  very  compli- 
cated; as,  for  example,  that  denominated  Chevaliers 


Fi<r.  14 


<  I  rill -stock,  than  which  there  are  none  better  adapted 
for  bringing  the  drill  to  bear  in  various  directions. 


DRILLS.  101 

(Fig.  14.)  An  other,  more  simple  in  construction, 
called  Merry  s  drill-stock,  has  recently  been  intro- 
duced to  the  notice  of  the  profession.  With  this, 
the  drill  can  be  applied  at  any  desired  angle,  the 
operator  having  as  complete  control  of  the  instru- 
ment as  of  the  common  straight  drill.     (Fig.  15.) 

Fijr.  15. 


Broaches. — The  broaches  of  three  or  four  sides  are 
made  of  the  best  steel,  and  are  of  various  sizes. 
They  are  constructed  both  of  a  straight  and  of  a  ta- 
pered form.  They  should  in  no  case  have  more  than 
a  spring  temper,  in  which  the  color,  when  drawing, 
is  a  deep  blue.  These  instruments  are  used  for  en- 
larging the  canals  of  fangs  for  the  purpose  of  filling. 
Six  or  eight  sizes  will  probably  meet  all  ordinary 
cases.  When  the  course  into  the  canal  is  tortuous, 
the  temper  of  the  instrument  should  be  so  low  as  to 
spring. 


EXCAVATORS. 


Of  the  small  cutting-instruments  for  opening  and 
forming  cavities  and  removing  decay  from  them, 
there  is  a  great  variety,  though  a  few  general  forms 


102 


INSTRUMENTS   FOR    FILLING. 


comprise  the  whole.  Hitherto  there  has  been  no 
very  systematic  arrangement  of  these  instruments, 
such  as  the  convenience  both  of  the  profession  and  of 
the  manufacturers  of  dental  apparatus  would  seem  to 
dictate.  In  a  classification  that  we  have  adopted 
and  found  very  convenient,  the  classes  are  arranged 
by  numbers,  the  most  simple  being  placed  under  the 
first,  and  under  each  successive  number  a  more  com- 
plicated form.  All  the  varieties  are  embraced  in  ten 
numbers,  which  are  represented  in  Fig.  16.     These 


Fie.  16. 


varieties  are  discriminated  by  the  forms  of  the  points 
and  their  position  on  the  shaft  to  which  they  are  at- 
tached, and  not  by  any  curve  which  the  shaft  may 
have  at  any  distance  from  the  point. 


EXCAVATORS.  103 

No.  1  has  simply  a  flat  point  slightly  curved,  with 
a  round  edge  transverse  to  the  shaft.  Four  sizes  will 
be  sufficient  for  ordinary  purposes. 

No.  2  has  a  flat  point  with  a  short  curve,  bringing 
the  point  to  a  right  angle  with  the  shaft ;  the  edge  is 
transverse.  This  differs  from  No.  1  in  having  the 
curve  more  short  and  abrupt,  and  the  edge  more 
nearly  square.     Four  sizes. 

No.  3  has  a  flat  point  with  a  square,  transverse 
edge,  which  rises  at  a  right  angle  from  the  shaft ;  the 
blade  being  from  one  to  two  lines  in  length.    Four  sizes. 

No.  4  has  a  flat  point,  curved  so  as  to  be  at  a  right 
angle  with  the  shaft ;  the  blade,  from  the  center  of 
the  curve  to  the  edge,  being  from  one  and  a  half  to 
three  lines,  and  the  edge  straight.     Four  sizes. 

In  each  of  the  foregoing  the  edges  should  expand 
slightly  in  width. 

No.  5  has  a  flat  point  with  a  square  edge,  which  is 
parallel  with  the  shaft,  and  rises  at  a  right  angle 
from  it.  The  blade  is  from  one  half  to  two  and  a 
half  lines  in  length,  and  from  one  half  to  one  line  in 
width,  with  no  expansion  at  the  edge.     Six  sizes. 

Nos.  6  and  7  are  right  and  left  excavators,  with 
flat  points  and  double  curves;  the  first  curve  being 
at  an  angle  of  about  twenty  degrees,  and  the  other 
lateral,  right  and  left,  reaching  from  the  beginning  of 
the  first  curve  to  the  point.  The  length  of  blade  is 
from  two  to  five  lines.     Four  sizes. 


104  INSTRUMENTS   FOR    FILLING. 

No.  8  has  a  crescent-shaped  point,  the  blade  rising 
by  a  small  attachment  from  the  shaft,  and  making  a 
right  angle  with  it.  The  edge  is  a  regular  curve, 
describing  about  two  fifths  of  a  circle,  and  is  parallel 
with  the  handle.  The  point  should  be  perfectly 
formed.     Six  sizes. 

No.  9.  The  form  of  the  point  is  the  same  as  in  No. 
8,  the  difference  being  in  the  position  of  the  blade, 
the  edge  of  which  is  transverse  to  the  shaft,  and  rises 
from  it  at  an  angle  of  one  hundred  and  thirty  degrees. 
Six  sizes. 

In  No.  10  the  point  has  the  same  shape  as  in  Nos. 
8  and  9.  The  cutting  edge  is  transverse  to  the  shaft, 
and  rises  by  a  small  neck  at  a  right  angle  from  it. 
Six  sizes. 

Such  are  the  most  important  forms  of  excavators ; 
though  modifications  will  be  required  for  particular 
cases.  While  Nos.  8,  9,  and  10  are  not  in  extensive 
use,  a  few  operators  have  used  them  for  some  years, 
and  prize  them  very  highly.  In  many  difficult  cases 
they  are  far  more  applicable  than  any  other  instru- 
ment we  have.  For  instance,  in  the  formation  of 
the  cervical  wall  of  a  proximal  cavity  in  any  of  the 
teeth,  but  particularly  in  the  superior  bicuspids  and 
molars,  there  is  no  other  instrument  so  applicable 
and  efficient  as  No.  9  :  with  it,  that  part  of  the  cavity, 
so  frequently  neglected,  is  just  as  easily  formed  as 
any  other. 


EXCAVATORS.  105 

Cases  will  occasionally  be  presented,  in  which  some 
curvature  of  the  shaft  of  the  instrument  will  be 
requisite.  But  no  more  curve  should  be  given  than 
may  be  absolutely  necessary,  since  it  is  impossible  to 
manipulate  with  the  same  precision  and  delicacy  with 
curved  as  with  straight  instruments.  The  degree  of 
curve  necessary  in  any  given  case  will  be  determined 
by  the  position  of  the  decay  on  the  tooth,  and  the 
location  of  the  latter  in  the  mouth. 

Of  the  Manufacture  of  Excavators. — For  making 
these  instruments,  there  should  be  selected  the  best 
cast-steel  wire,  No.  8.  This  should  be  forged  down 
so  as  to  leave  the  end  large  enough  to  form  the 
intended  point.  Nos.  1  to  6  inclusive,  may  be 
formed  by  forging,  and  afterward  dressing  up  with 
the  file.  Nos.  7  to  10  must  be  formed  by  the  files 
out  of  a  bulb  left  from  the  forge ;  for  which  purpose 
different  forms  and  sizes  of  files  will  be  required,  in 
order  definitely  to  shape  all  the  angles  and  points. 
In  heating  steel,  either  for  forging  or  tempering,  a 
full  red  heat  should  in  no  case  be  passed,  since  a 
higher  degree  than  this  spoils  it.  After  the  points 
are  formed,  and  made  smooth  with  an  emery  stick 
or  wheel,  they  are  to  be  tempered;  which  is  a  delicate 
process,  requiring  much  experience  and  care.  The 
point  should  be  warmed  in  a  spirit-lamp,  and  then 
covered  with  soap,  to  prevent  oxydation  and  scaling. 
The  instrument  is  then  brought  up  to  a  full  red  heat 


106  INSTRUMENTS   FOR    FILLING. 

with  a  spirit-lamp,  blowpipe,  and  charcoal,  and  sud- 
denly plunged  into  a  cake  of  soap  or  into  cold  water ; 
when  it  will  present  a  silvery  whiteness  :  the  steel  in 
this  condition  is  extremely  hard   and   as  friable  as 
glass.     It  then  should  be  polished  off  with  an  emery- 
stick  or  an  oilstone,  and  drawn  down  to  the  proper 
temper.     This  tempering  is  accomplished  by  placing 
the  edge  of  the  instrument  on  a  piece  of  cold  polished 
steel  or  iron,  and  its  shaft  near  or  in  the  flame  of  a 
small  spirit-lamp,  and  retaining  it  there  till  it  changes 
to  a  deep  blue  color,  graduated  down  to  the  point  in 
a  deep  straw  or  copper  hue.     The  purpose  in  holding 
the    point   of    the   instrument   on    a   piece    of    cold 
polished  iron  or  steel,  is,  that  the  heat  there  may  be 
subject  to  complete  control.     The  instrument  is  then 
to  be  polished  with  the  emery-wheel  and  dressed  up 
with  the  oilstone.     Of  the  various  methods  of  tem- 
pering, the  foregoing  is  equal,  and   in    convenience 
superior,  to  any  other. 

PLUGGING   INSTRUMENTS. 

For  introducing  and  consolidating  fillings,  a  great 
variety  of  instruments  is  in  use.  In  filling  with  gold 
in  some  of  the  forms  in  which  it  is  employed,  the 
plugging-pliers  are  required,  for  picking  up  the  pieces 
of  gold  and  placing  them  in  the  proper  positions  in 
the  cavity;   in   block-filling  they  are  indispensable. 


PLUGGING    INSTRUMENTS. 


107 


These  instruments  are  made  of  different  forms  and 
sizes — of  different  forms,  to  facilitate  access  to  cavi- 
ties inconveniently  located ;  of  different  sizes,  to  ac- 
commodate cavities  of  various  capacities.  For  a  large 
majority  of  cases,  they  require  a  slight  curve,  about 
half  an  inch  from  the  point;  for  some  cases,  however, 
the  curve  will  have   to   be  right-angled.    (Fig.  17.) 


Fist.  17. 


The  points  of  the  pliers,  when  shut  together,  should 
form  the  point  of  a  plugging  instrument,  so  that  it 
may  be  used  to  some  extent  for  consolidating  the 
gold.  This  instrument  should  be  about  five  inches 
long,  and  should  have  no  guidepin. 

The  forms  of  condensing  instruments  may  be  mul- 
tiplied to  an  almost  indefinite  extent.  They  are  all, 
however,  but  modifications  of  two  or  three  general 
principles.  The  particular  form  of  the  plugging  point 
will  be  determined  by  the  form  in  which  the  gold  is 
used.  "With  nonadhesive  gold,  small  square,  round, 
sharp  points,  of  various  curves,  will  all  be  required. 
(Fig.  18.)  These  points  are  easily  kept  in  proper 
condition,  and,  in  some  instances,  are  used  for  years 
without  any  change  or   repair.     But,  with  adhesive 


108 


INSTRUMENTS   FOR   FILLING. 


gold  in  any  of  its  forms,  the  points  all  require  to  be 
serrated.     There  are  three  or  four  varieties  of  these, 


Fig.  18. 


which  it  will  be  proper  to  describe.  The  first  is 
square,  and  slightly  bent  about  half  an  inch  from  the 
end,  which  is  formed  into  four  or  six  definite  sharp 
points  with  the  edge  of  a  thin  file.  Of  this  variety 
there  should  be  about  three  sizes,  the  largest  entering 
No.  18  of  Stub's  gauge,  and  the  smallest  No.  25. 
The  former  should  have  six  points,  and  the  other 
two  sizes  four.     (Fig.  19.)     The  cuts  upon  these  are 


Fig.  19. 


made  directly  across  the  end.  In  another  variety, 
the  end  is  rounded,  and  the  file  placed  upon  it  at  an 
acute  angle  with  the  side  of  the  instrument,  and  the 


PLUGGING   INSTRUMENTS. 


109 


cuts,  three  in  number,  are  made  to  the  center  of  the 
point,  which  thus  becomes  triangular,  or  three- 
pronged,  from  a  common  center.    (Fig.  20.)     Four  or 


Fiff.  20. 


five  sizes  of  these  may  be  employed,  ranging  from  18 
to  26,  Stub's  gauge.  A  thin  double  point,  from  26  to 
28,  is  in  many  cases  very  valuable.  Instruments  with 
a  condensing  surface  on  the  side,  in  stead  of  the  end, 
will  frequently  be  required  for  filling  lateral  cavities ; 
these  may  be  denominated  lateral  pluggers.  (Fig.  21.) 


Fijr.  21. 


This  condensing  surface  should  also  be  serrated,  as 
already  described.  An  instrument  square  at  the 
point,  ranging  from  18  to  22,  and  cut  upon  the  end 
by  passing  it  along  the  cuts  of  a  file  both  ways,  thus 
making  a  large  number  of  small  serrations  at  right 
angles  across  the  point,  is  valuable  for  consolidating 
the  surface  of  a  plug.     (Fig.  22.)     Operating  super- 


110 


INSTRUMENTS    FOR   FILLING. 


ficially,  on  the  principle  of  the  more  deeply  serrated 
instruments,  it  yet  leaves  the  surface  free  from  deep 


Fig.  22. 


pits  or  indentations,  and  still  so  impressed  that  it  will 
receive  and  retain  more  gold,  if  necessary,  as  it  would 
not  do,  if  the  end  of  the  instrument  were  perfectly 
smooth.  A  smooth-pointed  instrument  ma}'  he  ap- 
plied after  all  the  gold  has  been  added. 


Fig.  23. 


Fig.  23  is  an  instrument  with  file-cut  sides.  It  is 
valuable  for  dressing  down  approximate  fillings  to  a 
uniform  surface.  There  may  be  two,  one  with  the 
sides  parallel  with  the  shaft,  and  one  with  its  sides 
transverse  to  the  shaft;  it  terminates  in  a  sharp 
edge. 

In  many  cases  a  valuable  instrument  for  consoli- 
dating is  the  plugging  forceps,  the  general  form  of 


PLUGGING   INSTRUMENTS. 


Ill 


which,  except  the  beaks,  is  that  of  the  ordinary 
straight  extracting  forceps.  The  beaks  are  formed 
into  sockets  for  the  reception  of  the  plugging  points, 
one  of  which  is  of  the  common  construction,  but  the 
other  has  a  broad  flat  surface,  to  rest  against  the 
tooth.    (Fig.  24.)     This  instrument  is  applicable  only 

Fig.  24. 


in  certain  cases,  principally  in  rilling  proximal  cavi- 
ties. Its  main  advantage  consists  in  its  capability  of 
applying  a  strong  pressure  upon  the  rilling,  without 
affecting  the  socket.  Manipulation  with  it  is  less 
rapid  and  definite  than  with  the  ordinary  condensing 
instruments ;  and  with  it,  too,  there  is  much  danger 
of  fracturing  friable  teeth. 


THE    FILE. 


Of  this  valuable  and  indispensable  instrument 
there  is  a  variety  of  forms  used  by  the  dentist.  The 
thin  files  (Fig.  25)  are  chiefly  applicable  to  the  ante- 
rior; the  thick,  heavy,  knife-shaped  (Fig.  26),  to  the 
posterior  teeth.  The  latter,  to  facilitate  their  ap- 
proach  to  the   points  operated  upon,  have  various 


112 


INSTRUMENTS    FOR    FILLING. 


curves,  some  single,  others  double ;  the  double  being 
preferable,  since  they  bring  the  handle  of  the  instru- 


Fig.  25. 


ment  on  a  line  with  its  cutting  edge.     The  cuts  upon 
this  instrument,  too,  are  quite  various;  in  size  ran- 


Fig.  26. 


ging  from  very  coarse  to  very  fine,  and  in  obliquity 
from  a  line  almost  at  right  angles  across  it,  to  one  at 
an  angle  of  fortyfive  degrees.  These  cuts,  too,  are 
either  single  or  double,  the  double  being  those  made 
across  one  an  other.  The  single,  however,  are  pref- 
erable for  all  operations  on  the  teeth ;  and  the  more 


Tilt;    FILE. 


113 


oblique  are  to  be  recommended,  since  the)''  cause  less 
of  that  jarring,  unpleasant  sensation  to  the  patient. 

There  are  in  use  various  forms  of  file-carriers,  one 
of  which  is  represented  in  Fig.  27,  the  chief  advantage 


Fig.  27. 


of  which  is,  that  they  retain  the  file  much  more  firmly 
than  it  can  be  held  in  the  fingers.  These  carriers  are 
made  with  a  variety  of  curves,  to  accommodate  differ- 
ent positions.  There  is  also  a  great  variety  of  small 
file-point  instruments  for  dressing  down  fillings,  the 
more  important  of  which  are  represented  in  -Fig.  28. 

Fig.  28. 


The  Use  of  the  File. — When  a  separation  of  the 
teeth  is  requisite,  preparatory  to  filling,  it  is  accom- 
plished, either  in  whole  or  in  part,  with  the  file. 
Principally,  in  such  a  case,  its  use  is  restricted  to 
finishing  and  smoothing,  after  the  greater  portion  of 
the  work  has  been  done  with  the  heavy  cutting  in- 


114  INSTRUMENTS   FOR   FILLING. 

strument.  The  file  is  valuable  for  removing  super- 
ficial decay,  being  called  into  frequent  requisition  in 
caries  of  this  kind.  It  is  employed  to  dress  off  fangs 
preparatory  to  the  insertion  of  pivot  teeth ;  for  which 
purpose  it  is  required  to  be  of  a  round  or  half-round 
form.  It  is  used  for  dressing  off  sharp  portions  or 
edges  of  the  teeth,  that  may  be  injurious  to  the  soft 
parts,  and  in  some  cases  for  dressing  down  a  tooth 
that  is  elongated.  In  finishing  fillings  it  is  indispens- 
able. It  was  formerly  used  to  some  extent  in  the 
treatment  of  irregularity;  but  for  this  purpose  it  is 
now,  or  should  be,  abandoned. 

Mode  of  Using  the  File. — The  patient  should  be 
conveniently  seated,  with  the  head  on  a  firm  support, 
and  under  the  control  of  the  operator,  who  should 
occupy  a  position  at  the  right  of  the  patient  in  most 
cases,  so  disposing  the  head  of  the  latter  as  to  give 
the  freest  access  to  that  point  which  is  to  be  operated 
upon.  In  manipulating  with  the  file,  considerable 
skill  and  delicacy  are  requisite.  It  should  not  be 
held  with  a  stiff,  unyielding  grasp,  so  as  to  catch  and 
jar,  but  should  be  applied  with  a  gentle  pressure,  and 
drawn  across  the  tooth  with  a  free  and  flexible 
motion.  It  should  be  frequently  moistened,  and  not 
allowed  to  clog  with  the  filings,  being  kept  free  of 
these  by  constant  applications  of  the  brush.  A 
sharp,  new  file,  with  a  quick,  light  movement,  will 
cut  far   more  rapidly,  and  less  unpleasantly  to  the 


THE   FILE.  115 

patient,  than  one  that  is  dull  or  clogged,  applied 
with  a  heavy  pressure.  If  the  tooth  bone  is  sensi- 
tive, the  file  should  be  moistened  in  warm  water. 
When  a  file  has  become  clogged  with  the  dentine,  it 
may  be  perfectly  cleaned  by  immersing  it  a  few 
hours  in  dilute  hydrochloric  acid,  and  then  washing, 
boiling,  and  finishing  with  oil.  The  form  of  a  file 
may  be  changed  by  drawing  the  temper,  bending  it 
as  desired,  and  then  retempering. 

The  teeth,  while  being  filed,  should  be  supported 
by  the  fingers,  or  by  an  instrument  for  the  purpose ; 
or  a  cork  or  a  piece  of  soft  wood  may  be  inserted 
between  the  tooth  being  filed  and  the  teeth  of  the 
opposing  jaw,  and  the  pressure  thus  used  as  a  sup- 
port. The  tooth  being  sustained  in  this  manner, 
there  is  less  jarring  experienced  by  the  patient,  and 
less  liability  to  produce  irritation  of  the  periosteum. 
When  filing  the  anterior  teeth,  it  is  generally  better 
to  hold  the  file  in  the  fingers.  For  filing  the  incisors 
and  canines,  a  thin,  bevel-edged  file  is  to  be  pre- 
ferred. In  dressing  a  tooth  with  a  file,  the  last  that 
is  used  should  be  a  fine  one ;  after  the  application  of 
which,  the  surface  operated  upon  should  be  made  as 
smooth  as  possible  with  a  stone  and  burnisher,  or 
with  a  buff  charged  with  rotten-stone. 

In  separating  teeth  with  the  file,  where  but  one  is 
decayed,  care  should  be  taken  not  to  cut  the  sound 
one.     For  this  purpose,  it  will  often  be  necessary  to 


116  INSTRUMENTS    FOR    FILLING. 

have  a  beveled  edge  on  that  side  of  the  file  next  the 
sound  tooth  :  in  no  case  of  this  kind  should  a  square- 
edged  file  be  used.  In  cases  in  which  it  is  necessary 
to  file  teeth  that  are  somewhat  loose  in  the  sockets, 
and  whose  periosteum  is  in  a  state  of  irritation,  to 
build  up  a  wall  of  plaster  of  Paris  round  them,  per- 
mitting it  to  harden,  will  very  much  facilitate  the 
operation.  This  method  is  especially  to  be  recom- 
mended in  cases  where  it  is  necessary  to  dress  off  a 
considerable  portion  from  the  end  of  one  or  more 
inferior  front  teeth.  There  are  some  teeth  upon 
which  the  use  of  the  file  is  hardly  admissible ;  as,  for 
instance,  those  which  are  highly  vascular  and  predis- 
posed to  inflammation  of  the  dentine.  Because  the 
teeth  of  young  persons  are  of  this  character,  they 
should  be  filed  but  rarely,  if  at  all ;  but,  in  general, 
those  of  adults  may  be  filed,  if  properly,  with  impu- 
nity. The  file  should  not  be  used  upon  the  teeth, 
when  the  periosteum,  the  gums,  or  the  mucous  mem- 
brane is  in  a  diseased  condition,  or  strongly  predis- 
posed to  such  a  condition.  It  should  never  be  used 
for  the  correction  of  irregularity  of  the  teeth,  especi- 
ally when  they  are  sound ;  nor  should  it  be  employed 
to  separate  sound  teeth  to  introduce  clasps. 

Filing  of  the  teeth  is  an  operation  against  which 
there  has  been,  and  still  is,  much  prejudice,  though 
without  sufficient  cause :  whatever  injury  results 
from  this  operation,  is  mostly   from   the   imperfect 


THE    FILE.  117 

manner  in  which  it  is  performed,  and  from  subse- 
quent neglect  of  the  tooth  which  has  been  subjected 
to  it.  A  tooth  skillfully  treated  with  this  instru- 
ment, and  properly  cared  for  afterward,  will  not  be 
more  liable  to  decay  at  the  point  operated  upon,  than 
at  any  other  where  the  dentine  may  be  exposed. 


CHAPTER  V. 

SEPARATION   OF    THE   TEETH. 

In  most  cases  of  proximal  decay,  the  teeth,  before 
the  operation  of  filling  can  be  performed,  must  be 
separated;  though  cases  are  not  unfrequent,  where 
the  space  between  them  is  sufficient  to  admit  of  free 
manipulation  without  this  preliminary.  An  imper- 
fect accomplishment  of  this  first  step  in  the  process 
of  filling,  is  a  prolific  source  of  the  many  failures,  in 
proximal  cavities,  to  attain  to  efficient  and  durable 
results ;  for,  unless  this  step  be  thoroughly  performed, 
so  as  thus  to  make  room  for  the  free  introduction  and 
use  of  the  various  instruments  requisite,  no  part  of 
the  work  can  be  complete.  Though  the  most  com- 
mon object  for  which  teeth  are  separated,  is,  to 
obtain  space  for  free  manipulation  with  the  instru- 
ments in  filling,  yet  there  are  various  other  objects 
for  which  they  have  been  separated,  but  many  of 
which  are  now  better  reached  by  other  means.  It 
is  sometimes  necessary  to  cut  away  more  than  would 
otherwise    be   requisite,    in    order    to   remove    thin, 


SEPARATION  OF  THE  TEETH.  110 

friable  edges  of  the  cavity,  so  as  to  obtain  borders 
firm  enough  to  sustain  the  filling.  Teeth  are  in 
some  instances  separated  for  the  introduction  of 
clasps;  a  practice  always  to  be  deprecated,  since  it 
usually  proves  highly  injurious.  Though  the  prac- 
tice was  once  very  common,  yet  many  of  our  best 
operators  have  now,  with  good  reason,  abandoned  it 
altogether.  At  one  time,  too,  it  was  a  general  prac- 
tice to  separate  the  teeth  to  relieve  a  crowded  condi- 
tion ;  but  this,  also,  has  been  abandoned. 

There  are  two  methods  of  separating  the  teeth  : 
the  one,  to  cut  away  a  portion ;  the  other,  to  force 
apart  by  pressure,  acting  upon  one  or  more  teeth,  as 
the  circumstances  admit.  Formerly,  all  separations 
were  effected  with  the  file,  and  this  of  very  crude 
form  and  cut;  by  which  instrument,  especially  in 
unfavorable  cases,  much  injury  has  been  done. 
Though  the  file  is  a  valuable  instrument,  one  that 
no  other  could  supply,  yet,  for  removal  of  any  con- 
siderable portion  of  dentine,  it  is  not  to  be  recom- 
mended. Its  action  upon  inflamed  dentine  is  exceed- 
ingly painful,  besides  being  tedious  and  wearisome  to 
patient  and  operator ;  and  it  is  liable  to  irritate  the 
external  periosteum,  and  to  increase  inflammation. 
When  a  separation  is  to  be  made  that  requires  the 
removal  of  a  considerable  portion  of  the  tooth,  the 
chisels,  or  heavy  cutting  instruments,  are  to  be  pre- 
ferred.    These,  if  of  the  proper  form  and  temper,  and 


120  SEPARATION  OF  THE  TEETH. 

in  good  condition,  are  very  efficient  for  the  purpose, 
performing  the  work  far  more  rapidly  than  the  file, 
and  far  less  unpleasantly  to  the  patient.  They  effect 
the  removal  of  sensitive  dentine  with  but  little  or  no 
pain,  and  without  liability  to  increase  the  inflamma- 
tion, or  to  produce  irritation  or  disease  of  the  ex- 
ternal periosteum.  The  force  of  these  instruments 
is  sustained  by  the  entire  attachment  of  the  tooth, 
their  pressure  being  applied  almost  in  a  line  with  its 
axis.  Besides,  by  their  use,  the  contiguous  teeth  are 
not  liable  to  injury,  as  by  the  use  of  the  file  they 
often  are. 

The  manipulation  with  these  instruments  is  very 
simple.  For  separating  front  teeth,  the  instrument 
is  firmly  grasped  in  the  hand,  the  thumb  placed  on 
the  points  of  the  teeth,  and  the  edge  applied  at  the 
point  from  which  the  portion  is  to  be  removed,  and 
pressed  gradually  toward  the  gums,  not  thrust  into 
the  interval  as  a  wedge  before  it  has  freely  cut  its 
way.  In  this  manner,  as  much  of  the  dentine  as  it 
is  desirable  to  remove,  is  cut  off  in  a  few  moments. 
This  class  of  instruments  is  invaluable  for  forming 
the  V-shaped  spaces  between  the  bicuspids  and  the 
molars.  It  requires  a  prolonged  use  of  the  file  to 
make  these  separations  properly;  and  hence  the 
practice  of  attempting  to  fill  proximal  cavities  with- 
out any  separation  at  all,  by  operating  through  a 
small  opening  at  the  crown  angle  of  the  tooth,  or  a 


SEPARATION   OF   THE   TEETH.  121 

small  hole  drilled  through  its  outer  or  inner  portion. 
With  the  heavy  cutting  instruments,  points  upon  the 
teeth,  that  the  file  cannot  touch,  are  approached  and 
operated  upon  with  facilit}7. 

But  the  method  of  separation  by  pressure  is,  in 
many  cases,  to  be  preferred,  especially  in  the  case  of 
anterior  teeth,  whose  natural  form  it  is  important  to 
preserve.  In  order  to  a  successful  separation  in  this 
manner,  there  must  exist  certain  conditions.  In  the 
first  place,  there  is  to  be  sufficient  space  between  the 
contiguous  teeth  to  allow  the  desired  separation ;  for, 
if  all  the  teeth  are  remaining  and  stand  close  togeth- 
er, it  will  be  impossible  to  effect  much  separation 
by  pressure ;  but  if  there  is  a  slight  space  between 
some  of  the  adjacent  teeth,  or  if  a  neighboring  tooth 
has  been  removed,  the  object  may  be  readily  at- 
tained. The  gums,  periosteum,  etc.,  should  be  in  a 
healthy  condition;  for  much  injury  may  be  done  by 
attempting  to  separate  teeth  by  pressure,  when  the 
contiguous  parts  are  in  an  irritable  state.  In  persons 
of  a  neuralgic  diathesis,  in  those  whose  vital  energy  is 
weak,  and  particularly  in  those  whose  constitutional 
tendency  is  inflammatory,  this  operation  is  scarcely 
admissible.  If,  in  such  cases,  it  is  attempted  at  all, 
it  should  be  proceeded  with  very  carefully  and  grad- 
ually, and  would  better  be  preceded  by  constitu- 
tional treatment.  There  are  some  cases  in  which  it 
is  best  to  make  the  separation  partly  by  pressure,  and 


122  SEPARATION    OF    THE    TEETH. 

then  to  complete  it  by  dressing  off  the  thin,  friable 
edges  of  the  cavity  with  the  cutting  instrument  or 
the  file.  Whether  the  process  is  to  be  wholly  or 
only  partly  accomplished  by  pressure,  should  be  de- 
termined beforehand. 

Various  materials  have  been  employed  for  sepa- 
rating the  teeth  by  pressure,  the  chief  of  which  are 
cotton,  wood,  India  rubber,  and  ligatures.  The  con- 
dition and  character  of  the  parts  to  be  operated  upon 
will  indicate  the  material  best  adapted  in  any  given 
instance.  In  a  good  constitution,  with  the  teeth 
firmly  set,  and  the  contiguous  parts  healthy,  wood  or 
India  rubber  may  be  applied ;  but  in  cases  of  an  op- 
posite character,  a  more  yielding  and  tractable  mate- 
rial is  indicated.  The  degree  of  pressure  to  be  ap- 
plied and  continued,  will  be  determined  by  the 
susceptibility  of  the  parts  to  irritation.  Soreness 
usually  occurs  in  a  few  hours  after  the  introduction 
of  the  material.  The  pressure  should  be  gradual  and 
constant,  slight  at  first,  and  increased  in  force  as  the 
patient  will  bear;  the  increase  being  made  every  day, 
and  continued  till  ample  space  is  obtained.  The 
time  necessary  for  the  completion  of  this  process  is 
from  ten  to  twelve  days ;  only  one  separation  should 
be  made  at  a  time.  The  teeth  should  be  retained 
apart  till  the  soreness  has  abated,  before  the  opera- 
tion. If  not  thus  retained  too  long,  they  will  return 
to  their  former  position.    It  is  by  some  supposed  that 


SEPARATION  OF  THE  TEETH.  123 

separation  by  pressure  is  admissible  only  in  the  case 
of  the  young,  or  those  under  thirty  years  of  age.  It 
is  true  that  they  are  the  most  susceptible;  but  the 
operation  is,  under  favorable  circumstances,  proper  at 
any  age. 


CHAPTER  VI. 

FILLING    OF    TEETH. 

The  operation  of  filling  teeth  is  an  interesting  and 
important  one,  requiring  for  its  successful  accomplish- 
ment peculiar  talent  and  large  experience.  It  is  the 
only  means  as  yet  ascertained  of  completely  effecting 
the  object  for  which  it  is  employed,  namely,  arrest  of 
decay  and  preservation  of  the  organs.  Therapeutic 
agents  avail  but  little  here,  so  low  is  the  organization, 
and  so  feeble  the  vital  power.  Nature,  so  efficient  in 
more  highly  organized  structures,  does  but  little,  in 
disease  of  the  teeth,  toward  arrest  or  restoration. 
Yet,  on  the  other  hand,  these  organs  are  less  liable 
to  decomposition  by  the  action  of  foreign  substances ; 
indeed,  the  enamel  is  almost  invulnerable  to  any 
agents  to  which  it  is  ordinarily  exposed.  The  den- 
tine, however,  is  more  easily  acted  upon,  and,  when 
there  is  defect  in  the  enamel,  is  very  liable  to  injury. 

Scarcely  an  individual  in  our  country  arrives  at 
mature  age  with  a  perfect  set  of  teeth ;  indeed,  nine 
tenths  of  our  people  have  decayed  teeth  at  an  early 
period  of  life.     Hence,  for   beautifying,   preserving, 


EXAMINATION.  125 

supplying  these  organs,  art  is  in  constant  requisition ; 
and,  in  these  respects,  art  has  made  great  achieve- 
ments. In  the  operation  of  filling  the  teeth,  espe- 
cially, its  achievements  are  conspicuous ;  and  here  is 
scope  for  the  highest  skill.  Every  successive  step  in 
the  process  of  filling  a  tooth  demands  a  complete  and 
conscientious  application  of  the  most  efficient  and 
best  adapted  formulas  of  the  art.  In  the  following 
remarks,  it  is  proposed  to  analyze  this  whole  process, 
examining,  in  their  order,  the  various  steps  necessary 
to  be  taken,  and  endeavoring  to  inculcate  the  true 
methods  of  accomplishing  them. 

EXAMINATION. 

When  a  case  is  presented,  there  should  first  be  a 
thorough  examination,  since  by  this  all  the  subse- 
quent work  will  be  modified.  The  points  to  be  noted 
in  the  examination  are  as  follows  : 

The  temperament ;  the  present  health ;  the  consti- 
tutional tendencies;  the  secretions,  the  saliva  and 
the  mucus;  the  mucous  membrane  and  the  gums; 
the  constitution  and  condition  of  the  teeth ;  the  num- 
ber of  them  remaining  in  the  mouth ;  the  num- 
ber affected  ;  and  the  extent  and  nature  of  the  decay, 
and  the  character  of  the  agents  producing  it.  By 
the  examination  we  ascertain  how  to  proceed  in  the 
operation;  if  much  or  but  little   labor  is  required; 


126  FILLING    OF   TEETH. 

whether  the  operation  will  be  a  simple  or  a  difficult 
one;  and  if  difficult,  what  circumstances  render  it  so: 
and,  besides,  some  conclusion  is  arrived  at  in  regard 
to  the  permanency  of  the  operation. 

OPENING. 

The  next  step  is  to  open  the  cavity  of  decay,  so 
that  it  may  be  approached  and  operated  upon  at  all 
points.  The  particular  manner  of  performing  this  is 
determined  by  the  extent  of  the  decay,  and  its  posi- 
tion upon  the  tooth.  In  all  cases  the  opening  should 
be  such  as  to  give  free  access  to  all  parts  of  the 
cavity,  for  removing  effectually  the  decayed  portion, 
for  perfectly  forming  the  cavity,  and  for  introducing 
and  thoroughly  consolidating  the  filling.  In  central 
crown  cavities  of  the  molars  and  bicuspids,  the  pro- 
jecting or  pendent  portions  of  enamel  should  be  cut 
away.  There  are  cases,  however,  where  such  por- 
tions are  firm  and  not  liable  to  be  broken,  and  where 
they  can  be  well  sustained  by  filling  under,  in  which 
it  is  admissible  to  leave  some  projection.  This  is 
true  of  only  those  teeth  which  are  of  good,  firm 
texture.  There  are  these  two  objections  which  may 
exist  to  these  abrupt  projections  of  enamel :  it  is  very 
difficult,  and  in  many  cases  impossible,  to  fill  perfectly 
beneath  such  portions ;  and  again,  they  are  very 
liable  to  be  broken  down  during  mastication. 


OPENING. 


127 


For  opening  up  these  cavities,  in  many  cases  the 
bur  drill  alone  will  be  quite  sufficient;  those  of  dif- 
ferent sizes  being  employed,  to  open  up  the  orifice 
gradually,  so  that  too  much  violence  may  not  be  done 
to  the  teeth.  In  all  very  small  cavities,  the  bur  is 
all  that  is  required. 

In  cases  where  the  decay  is  more  extensive,  and 
the  cavity  larger,  the  chisel  or  heavy  cutting  instru- 
ment, in  connection  with  the  drill,  will  be  found  very 
useful.  An  instrument  first  brought  to  the  notice  of 
the  profession  by  Dr.  Forbes,  is  very  valuable  for 
opening  and  enlarging  crown  cavities  of  the  molars. 
It  consists  of  a  socket-handle,  which  receives  a  screw- 
clamp,  and  this  receives  the  bits;  which  are  of 
various  forms,  such  as  the  gouge-,  chisel-,  and  V-shape  : 
these  fit  into  the  clamp,  and  are  grasped  by  it,  as  it 

Fig.  29. 


is  screwed  into  the  handle.  (Fig.  29.)  By  its  use 
the  operation  will  be  very  much  facilitated,  and  less 
jarring  will  be  communicated  to  the  tooth ;  but  after 


128  FILLING    OF    TEETH. 

it  is  used,  the  bur  will  be  required  to  give  a  smooth, 
uniform  border  to  the  cavity.  In  these  cases,  the 
orifice  should  be  almost  or  quite  as  large  as  the 
cavity  within.  In  proximal  decay,  the  cavity  must 
be  sufficiently  exposed  to  enable  the  operator  to  see 
distinctly  into  it,  and  to  manipulate  freely,  in  all 
parts  of  the  operation.  These  cavities  may  be 
exposed  by  the  use  of  the  chisel  or  the  file,  or  by 
pressure. 

REMOVAL    OF   DECAY. 

After  the  cavity  is  opened,  the  next  step  in  order 
is  the  removal  of  the  decayed  dentine.  As  a  general 
rule,  this  should  be  entirely  removed.  There  is, 
however,  some  variety  of  opinion  upon  this  subject. 
This  difference  of  opinion  is  in  regard  to  cases  where 
an  entire  or  a  partial  decomposition  of  the  dentine 
has  taken  place  quite  to  the  pulp,  and  where,  by  its 
removal,  the  pulp  would  be  exposed.  It  is  main- 
tained by  some  that  decayed  dentine  affords  a  better 
protection  to  the  nerve  than  any  artificial  covering; 
and  hence  it  is  better  to  let  it  remain,  since  its 
adaptation  to  the  pulp  is  more  complete ;  and  it  is 
not  in  every  sense  a  foreign  substance. 

On  the  other  hand,  it  is  contended  that  the  de- 
cayed dentine,  being  in  an  abnormal  condition,  will 
irritate,  and  in  many  cases  ultimately  destroy  the 
pulp.     And   again,   that  there  is   danger  of  making 


REMOVAL    OF   DECAY.  129 

undue  pressure  upon  the  pulp,  in  filling  on  such  soft- 
ened portion. 

In  many  cases,  it  is  maintained  that  partially  de- 
composed dentine  will  become  dense  again,  if  pro- 
tected from  the  influence  of  foreign  agents  that  de- 
compose it.  This  sometimes  would  seem  to  be  true. 
For  in  some  cases  where  fillings  have  been  introduced 
into  cavities,  at  the  bottom  of  which  a  softened  por- 
tion of  dentine  covered  the  nerve  pulp,  on  removing 
them  in  from  one  to  five  years  afterward,  the  whole 
walls  of  the  cavity  were  found  to  be  equally  and 
normally  dense.  This,  perhaps,  would  occur  only  in 
good  constitutions,  and  under  favorable  circum- 
stances; but  with  such  constitutions  and  circum- 
stances, where  the  softening  is  not  too  extensive,  and 
the  decomposition  but  partial,  it  may  be  permitted  to 
remain,  with  a  strong  probability  of  a  favorable 
result.  This  would  certainly  be  better  than  to  cut 
it  all  away  and  expose  the  nerve,  and  perhaps  wound 
it,  and  then  endeavor  to  cover  it  with  some  wholly 
foreign  material  that  would  not  be  perfectly  adapted 
to  it,  that  would  press  a  little  too  hard  at  one  point, 
and  not  touch  at  an  other,  and  that  would  be  quite  as 
liable  to  be  pressed  down  on  the  pulp  as  the  softened 
dentine. 

In  this  discussion,  much  depends  upon  the  point 
whether  partially  decomposed  dentine  can  retain  its 
vitality.     This   it  is  not   now  proposed  to  consider. 


130  FILLING    OF    TEETH. 

There  are  some  particulars  in  regard  to  the  removal 
of  decay,  however,  about  which  there  is  no  diversity 
of  opinion :  first,  that  all  decomposed  dentine  should 
be  removed  from  all  parts  of  the  cavity,  where  the 
pulp  would  not  be  exposed  or  injured  thereby ;  and 
that  in  all  cases  it  should  be  entirely  removed  from 
the  lateral  walls  of  the  cavity,  and  especially  from  the 
vicinity  of  the  orifice.  Even  discolored  dentine  should 
be  removed  from  this  point. 

Dentine  often  becomes  changed  in  color  when 
there  is  no  apparent  decomposition ;  such  portion  is 
usually,  though  not  always,  without  vitality.  It  is 
not  important  to  remove  such  changed  portion,  ex- 
cept for  the  appearance  of  the  tooth  ;  it  will  produce 
no  change  upon  the  living  or  normal  part  beyond  it ; 
and  it  is  better  material  to  be  in  contact  with  the 
living  part  than  the  metal  of  which  the  filling  is 
made. 

Decayed  dentine  is  readily  removed  with  the  ex- 
cavators. In  any  given  case,  such  instrument  should 
be  selected  as  would  be  best  adapted  for  the  purpose, 
as  well  in  regard  to  size  and  the  form  of  its  edge,  as 
to  the  curvature,  or  inclination,  of  its  shaft.  The 
edge  of  the  instrument  should  come  upon  the  walls 
of  the  cavity  at  such  an  angle  as  to  accomplish  the 
work  most  efficiently.  It  should  be  very  sharp,  and 
pressed  firmly  to  the  bottom  of  the  decay  at  one  side, 
so  as  to  remove  the  principal  part  at  one  cut.     With 


FORMING   CAVITIES.  131 

the  proper  instrument,  and  that  in  the  right  con- 
dition, all  the  decay  should  be  removed  from  any 
cavity  by  a  very  few,  firm,  steady  strokes.  By  this 
method  less  pain  is  caused  the  patient,  and  the  work 
of  the  operator  is  facilitated.  It  is  intolerable  to 
think  of  being  subjected  to  an  awkward,  clumsy 
hand,  with  a  dull,  ill-shaped  excavator,  scratching 
upon  the  surface  of  a  decayed  tooth,  for  a  length  of 
time,  apparently  to  the  patient,  interminable. 

FORMING   CAVITIES. 

The  next  step  in  the  operation  is  the  formation  of 
the  cavity.  By  this  the  cavity  is  so  formed  that  it 
will  retain  the  rilling  when  properly  introduced.  In 
very  few  cases  is  the  cavity  of  proper  form  when  the 
decay  is  removed.  Much  time,  patience,  and  labor 
are  required  of  the  operator,  for  the  proper  accom- 
plishment of  this  part  of  the  work,  and  much  endu- 
rance on  the  part  of  the  patient.  Excavation  is  often 
necessary  to  give  a  regular  form  to  the  cavity;  and 
in  this  process  there  are  several  particulars  worthy  of 
consideration.  The  great  object,  however,  is  to  give 
to  the  cavity  such  a  form  as  will  most  certainly  re- 
tain the  filling  in  place.  The  cutting  for  the  forma- 
tion of  the  cavity  should  be  accomplished  with  the 
least  possible  loss  of  healthy  dentine;  which  is  a 
point  upon  which  good  judgment  should  be  exercised. 


132  FILLING    OF   TEETH. 

The  strength  of  the  walls  of  the  cavity,  and  the 
ability  of  the  parts  to  withstand  the  pressure,  both  in 
the  introduction  and  consolidation  of  the  filling  and 
in  the  act  of  mastication,  should  be  well  noted.  It 
may  be  regarded  as  a  rule  from  which  there  should 
scarcely  ever  be  a  departure,  that  the  enamel  should 
never  be  encroached  upon  in  excavating  to  give  form 
to  a  cavity.  When  there  is  but  a  lining  of  dentine 
at  any  given  point  on  the  enamel,  after  the  decay  is 
removed,  it  should  remain  for  the  preservation  of  the 
enamel ;  it  should  not  be  cut  through  either  by  pits 
or  by  grooves,  much  less  should  any  considerable  por- 
tion be  removed. 

There  are  cases  occasionally  in  which  the  dentine 
is  wholly  decayed,  and  its  removal  lays  bare  the 
enamel ;  when  such  a  case  occurs,  the  enamel  should 
be  retained  as  perfect  as  possible,  and  no  attempt 
made  to  form  pits  or  grooves  in  it.  The  reason  for 
this  is  found  in  the  friability  of  the  enamel. 

It  may  be  regarded  as  an  axiom,  that  where  it  is 
necessary  to  cut  the  healthy  dentine  to  give  proper 
form  to  a  cavity,  it  should  be  done  at  that  part  of 
the  cavity  where  the  tooth  will  suffer  least  from  the 
loss.  The  precise  point  and  amount  of  cutting  will 
be  determined  by  the  form  and  size  of  the  cavity,  and 
the  amount  of  solid  dentine  remaining  after  the  decay 
is  removed. 

In  small  cavities,  where  there  is  sufficient  material 


FORMING   CAVITIES.  133 

to  work  upon,  the  object  is  to  give  the  cavity  a 
regular  form,  and  make  the  retaining  points  where  it 
is  most  convenient. 

In  large  cavities,  where  one  side  of  the  tooth  is 
weak,  places  must  be  selected  for  making  the  retain- 
ing points,  that  will  not  affect  the  weak  point.  Fre- 
quently, in  proximal  decays  of  the  anterior  teeth,  the 
labial  and  palatal  walls  are  friable,  and  would  be 
easily  broken ;  much  cutting  upon  such  walls  would 
not  be  admissible.  Again,  the  decay  often  extends 
toward  the  point  of  the  tooth,  down  to  the  union  of 
the  labial  and  palatal  plates  of  the  enamel ;  in  cases 
of  this  kind,  all  that  can  be  done  at  this  point  is  to 
remove  the  decay;  and  fracture  will  sometimes  occur, 
even  in  accomplishing  this. 

In  some  cases,  as  in  the  crown  cavities  of  the 
molars,  the  cavity  will  be  nearly  or  quite  of  proper 
form  when  it  is  perfectly  opened  up,  and  the  decay 
all  removed.  This  is  the  case  when  the  decay  is 
confined  to  a  simple  perforation  of  the  dentine,  with- 
out any  lateral  extensions.  In  proximal  cavities, 
there  is  always  more  or  less  excavation  of  the  solid 
dentine  required,  to  give  the  cavity  proper  form. 

There  is  no  definite  rule  for  the  formation  of  cavi- 
ties, that  will  be  applicable  in  all  cases.  The  form 
will  be  modified  by  the  tooth,  the  position  of  the 
decay  upon  it,  and  the  extent  and  ramifications  of 
the  decay.     It  is  given,  by  some,  as  a  rule,  that  the 


134  FILLING    OP   TEETH. 

depth  of  a  cavity  should  be  equal  to  its  least  diameter. 
This  is  a  direction,  however,  of  no  general  applica- 
tion, for  many  cavities  will  be  much  deeper  than  the 
greatest  diameter,  as  in  crown  cavities  of  the  molars ; 
and  the  reverse  will  often  occur,  as  in  labial  cavities 
of  the  superior  incisors,  and  in  proximal  cavities  of 
the  molars,  in  which  it  would  be  impossible  to  make 
anything  like  an  approach  to  this  rule,  without  ex- 
posing the  nerve,  and  even  cutting  through  the  nerve- 
chamber. 

A  general  direction,  and  one  that  we  think  good, 
and  applicable  in  many  cases,  especially  in  crown 
cavities  of  the  molars,  and  in  almost  any  of  the  deep 
perforations  by  decay,  is,  to  make  the  walls  of  the 
cavity  as  nearly  as  possible  parallel  with  one  an  other. 
This  rule  is  applicable  in  almost  all  small  cavities. 

In  medium  or  large-sized  cavities,  it  is  admissible 
to  leave  them  slightly  larger  at  the  bottom  than  at 
the  orifice,  if  circumstances  require ;  a  large  cavity  of 
this  form  can  be  perfectly  filled,  when  a  small  one 
could  not,  from  the  fact  that,  in  the  former,  there  is 
more  room  to  manipulate  with  the  instrument,  in 
introducing  and  consolidating  the  filling. 

Cavities  that  are  larger  within  than  at  the  orifice, 
should  have  their  walls  perfectly  plain,  smooth  sur- 
faces, free  from  transverse  grooves  or  depressions,  so 
that  the  gold  may  be  perfectly  adapted  to  them. 

It  is  sometimes  necessary  to  leave  a  cavity  slightly 


/ 


FORMING   CAVITIES.  135 

larger  at  the  orifice  than  at  the  bottom.  This  may 
be  done  by  a  converging  inclination  of  the  wall  of 
one  or  more  sides  of  the  cavity.  When  there  is  an 
inward  inclination  of  the  wall  at  one  side  of  the 
cavity,  the  general  form  may  be  such  as  to  retain  a 
rilling  perfectly,  for  there  may  be  two  opposite  sides 
parallel,  or  even  divergent ;  in  that  case,  the  axis  of 
the  cavity  will  not  be  in  the  direction  of  the  center 
of  the  crown. 

Two  opposite  sides  may  converge  and  the  others 
diverge,  and  a  filling  be  retained  firmly.  When  two 
contiguous  sides  have  the  same  converging  inclina- 
tion, making  the  orifice  larger  than  the  interior,  if 
the  walls  are  smooth,  plain  surfaces,  a  filling  will  not 
be  retained ;  but  retaining  points  may  be  made  by 
forming  transverse  grooves,  or  pits  upon  them,  and 
by  this  means  the  filling  be  firmly  retained.  As  a 
general  rule,  it  will  be  necessary,  when  the  orifice  is 
larger  than  the  cavity  within,  to  make  grooves  or  pits 
on  the  walls.  For  these  the  proper  points  should  be 
selected. 

If  the  cavity  is  large,  and  the  walls  near  the  orifice 
thin,  and  liable  to  be  broken,  the  situation  of  the 
grooves  or  undercutting  should  be  farther  within  the 
cavity  than  if  the  walls  are  firm  out  to  the  edge. 
Sometimes  it  is  best  to  make  little  pits  at  the  bottom 
of  such  cavities  for  retaining  points.  In  cases  where 
it  is  necessary  to  make  an  undercutting,  one  or  two 


136  FILLING    OF   TEETH. 

little  transverse  grooves  upon  one  side  will  be  suffi- 
cient, and  in  no  case  on  more  than  two  sides,  leaving 
the  others  perfectly  plain  surfaces. 

In  the  formation  of  retaining  points  in  difficult 
cavities,  there  is  considerable  diversity  of  practice — 
undercutting  and  grooving  have  been  very  com- 
monly employed.  An  other  method  has  been  very 
frequently  adopted  during  the  last  three  or  four 
years,  namely,  that  of  drilling  little  holes  or  pits  into 
the  dentine  at  the  most  favorable  points,  these  taking 
different  directions.  This  kind  of  retaining  points  is 
much  better  calculated  to  answer  the  purpose,  in 
filling  with  crystal  gold,  or  adhesive  foil  by  Dr. 
Arthur's  method,  than  with  the  ordinary  foil  after 
the  old  methods.  When  these  perforations  are  made 
at  different  inclinations,  and  then  perfectly  filled  with 
adhesive  gold  of  any  kind,  the  filling  will  certainly 
be  retained  in  place.  For  making  these  perforations, 
an  English  broach  and  a  small  square-edged  drill  are 
quite  sufficient. 

Such  retaining  points  are  seldom  or  never  required 
in  crown  cavities  of  the  molars  ;  but  in  proximal 
cavities  they  are  frequently  employed  with  great 
advantage.  In  forming  them,  great  care  should  be 
exercised,  lest  the  nerve-chamber  is  approached  by 
the  instrument.  In  almost  all  cases,  the  proper  point 
for  forming  them  is  at  the  bottom  of  the  cervical  wall 
of  the  cavity. 


FORMING    CAVITIES.  137 

An  other  particular  to  which  attention  should  be 
given  is  the  border  of  the  orifice.  It  should  always 
be  an  object  to  secure  an  even,  smooth,  and  strong 
border  to  the  orifice  of  the  cavity.  It  is  impossible 
to  make  a  good  finish  with  a  rough,  uneven  border; 
the  filling  is  also  more  exposed  to  injury  by  mastica- 
tion. The  integrity  of  a  smooth,  plain  surface  is  per- 
fectly retained  under  influences  that  would  break  up 
and  destroy  an  uneven  one.  It  is  also  very  desirable 
to  have  a  firm  margin ;  to  obtain  this,  it  is  often 
necessary  to  cut  away  more  than  would  otherwise  be 
desirable.  A  smooth,  firm  border  should  not  be  sacri- 
ficed for  the  form,  and  especially  in  the  posterior 
teeth.  It  is  very  objectionable  to  some  persons  to 
have  the  perfect  form  of  the  front  teeth  marred  or 
changed  ;  but  it  should  be  remembered  that  even  a 
front  tooth,  one  third  cut  away,  and  so  filled  as  to  be 
permanently  preserved,  is  far  more  valuable  than  an 
artificial  one. 

An  other  particular  that  should  always  be  observed, 
is,  to  obviate  all  acute  angles.  These  are  seldom  or 
never  found  in  proximal  cavities  of  the  molars  and 
bicuspids;  occasionally  they  are  found  in  proximal 
cavities  of  the  cuspids,  and  frequently  in  proximal 
cavities  of  the  incisors,  particularly  at  that  part  of 
the  cavity  next  to  the  cutting  edge  of  the  tooth. 
Such  angles  are  very  often  found  also  in  crown 
cavities  of  the   molars,  where   there  is  an  extension 


138  FILLING    OF   TEETH. 

of  the  decay  along  one  or  more  of  the  fissures  of  the 
crown. 

It  is  difficult — almost  impossible — to  fill  perfectly 
a  sharp  angle,  and  hence  the  necessity  of  obliterating 
such  when  they  occur.  This  may  be  done  either 
with  a  small  delicate  cutting  instrument,  or  with  a 
small  bur  drill.  It  is  an  operation  requiring  great 
care  and  delicate  manipulation,  at  least  so  far  as  the 
anterior  teeth  are  concerned.  When  a  sharp  angle 
occurs  in  the  proximal  cavities  of  the  front  teeth, 
it  is  usually  near  the  cutting  edge  of  the  tooth, 
just  at  the  union  of  the  labial  and  palatal  plates  of 
enamel.  A  small  chisel-shaped  instrument  is  very 
good  for  cutting  out  such  angles :  indeed,  in  fissures 
of  crown  cavities  of  molars,  where  the  decay  extends 
backwards,  the  straight,  chisel-shaped  instrument  is 
just  adapted  to  this  purpose;  but  when  there  is  an 
anterior  extension,  the  instrument  should  be  curved 
to  almost  a  right  angle,  and  forced  down  by  pressure 
of  the  thumb  of  the  left  hand.  Some  good  operators 
recommend  a  slight  reaming  at  the  orifice  of  all  cavi- 
ties, where  it  can  be  accomplished.  The  object  of 
this  is  twofold  :  to  remove  the  sharp  angle  at  the  ori- 
fice of  the  cavity,  as  it  is  liable  to  be  roughened  in 
putting  in  the  filling ;  and  to  give  a  better  border  to 
the  filling.  In  making  this  bevel,  the  bur,  if  one 
is  used,  should  be  but  little  larger  than  the  orifice  of 
the  cavity.     The  cutting  should  be  but  slight — just 


DRYING    CAVITIES.  139 

sufficient  to  remove  the  sharp  corners ;  much  cutting 
here  would  give  too  thin  and  yielding  an  edge  to  the 
filling. 

DRYING    CAVITIES. 

After  a  cavity  is  properly  formed,  it  should  be 
thoroughly  cleaned  and  dried.  Every  particle  of  de- 
tached bone  or  foreign  substance  should  be  removed ; 
during  the  excavation  every  thing  should  be  kept 
out,  every  fragment  removed  as  soon  as  it  is  de- 
tached ;  but  generally  there  is  something  of  the  kind 
to  remove  after  the  cavity  is  formed.  This  may  be 
done  probably  better  with  a  syringe  than  by  any 
other  method ;  this,  however,  used  in  connection  with 
a  moist  lock  of  cotton  on  a  probe,  will  serve  to  re- 
move every  extraneous  material  that  may  be  in  the 
cavity.  Any  foreign  substance  remaining  in  the 
cavity  prevents  a  perfect  adaptation  of  the  gold  to 
the  part,  and  consequently  as  perfect  an  attachment 
as  would  otherwise  be  obtained.  After  washing  out 
thoroughly,  wipe  out  with  successive  locks  of  dry  cot- 
ton, till  all  the  moisture  is  removed.  The  ordinary 
cotton  will  not  accomplish  this  very  effectually.  By 
washing  cotton  in  sulphuric  ether,  it  is  much  im- 
proved for  this  purpose.  The  ether  removes  a  peculiar 
oily  substance  from  it,  and  thus  increases  its  capacity 
to  absorb  moisture.  Ether  or  chloroform  will  either 
answer  the  purpose;   or  a  boiling  of  the  cotton  in 


140  FILLING   OF   TEETH. 

water  in  which  there  is  a  small  portion  of  carb.  soda, 
or  some  such  alkali,  for  a  short  time,  will  accomplish 
the  same  thing.  Bibulous  and  blotting  paper  have 
been  employed  for  this  purpose ;  and  by  some  they 
are  preferred.  Prepared  flax  has  likewise  been  used. 
Either  of  these  is  no  better  than  cotton  well  prepared. 
The  respect  in  which  the  paper  is  any  better  than 
common  cotton,  is,  that  it  has  the  same  treatment  in 
effect  as  the  prepared  cotton. 

With  none  of  these  things  can  a  cavity  be  made 
absolutely  dry.  It  is  not  necessary  to  have  absolute 
dryness  to  make  a  good  filling,  yet  a  more  perfect 
filling  can  be  made  where  that  condition  is  obtained. 
Gold  takes  a  better  hold  upon  a  perfectly  dry,  than 
upon  a  moist  surface.  This  is  quite  apparent  in  the 
following  experiment :  Place  two  or  three  blocks  of 
gold  in  any  ordinary  cavity,  wiped  as  dry  as  possible, 
and  press  them  firmly  in  place,  consolidating  them  as 
much  as  would  be  done  in  filling,  and  then  test  the 
attachment  by  removal.  Afterward  reduce  the  same 
cavity  to  absolute  dryness,  take  the  same  amount  of 
gold,  in  the  same  form,  and  place  it  in  the  cavity, 
and  consolidate  as  before,  at  the  same  poiut  in  the 
cavity;  and  then  test  its  attachment  in  the  same 
manner.  The  latter  will  be  found  much  more  firmly 
attached  than  the  former. 

But  it  is  objected  that  this  is  useless,  inasmuch  as 
the  natural  moisture  of  the  tooth  is  removed,  by  pro- 


DRYING    CAVITIES.  141 

ducing  absolute  dryness,  and  that  this  will  soon 
return,  and  then  the  cavity  will  be  no  dryer  than  it 
could  have  been  made  with  good  cotton  or  paper. 
Admitting  this,  perfect  dryness  will  remain  long 
enough  for  the  introduction  of  the  filling.  And  if 
this  is  facilitated  by  absolute  dryness,  and  a  better 
adaptation  and  attachment  obtained,  then  it  is  de- 
sirable to  obtain  that  condition. 

It  has  already  been  remarked  that  perfect  dryness 
can  not  be  obtained  with  cotton  or  paper.  To  warm 
these  on  a  hot  metallic  plate,  after  being  wrapped  on 
the  instrument,  will  very  much  increase  their  effici- 
ency in  removing  moisture.  Asbestos  wrapped  on  a 
small  bulb-pointed  instrument,  and  heated,  is  very 
good  for  drying  out  cavities ;  with  it,  perfect  dryness 
can  be  obtained,  as  it  can  be  reheated  and  applied 
as  often  as  necessary.  To  prepare  this,  select  a 
proper-sized  bulb-pointed  instrument ;  a  worn-out  bur 
drill  answers  well ;  and  fold  over  it  fibers  of  asbestos, 
passing  them  a  little  way  beyond  the  bulb  on  the 
shaft  of  the  instrument,  and  there  binding  them 
firmly  on  with  fine  platinum  wire ;  and  the  instru- 
ment is  ready  for  use.  An  other  method  of  obtaining 
perfect  dryness — one  that  is  very  certain  in  its 
result — is  to  throw  a  jet  of  warm  air  into  the  cavity. 
This  is  accomplished  by  a  little  instrument,  simple 
in  structure  and  easily  used.  (Fig.  30.)  It  consists 
of  a  small  blowpipe  with  a  cylinder  an  inch  long, 


142 


FILLING   OF    TEETH. 


and  half  an  inch  in  diameter;  this  is  placed  down 
within  two  inches  of  the  point  of  the  instrument. 
This  cylinder  is  either  made  of  very  heavy  metal,  or 
filled  with  wire  or  something  that  will  retain  heat ; 


Fiff.  30. 


on  the  other  end  is  attached  a  stiff  India-rubber  ball 
with  an  opening  one  and  a  half  lines  in  diameter. 
By  placing  the  thumb  upon  this  opening,  and  making 
compression,  a  jet  of  air  is  forced  through  the  point 
of  the  pipe,  and  the  cylinder  being  previously  heated, 
the  temperature  of  the  jet  will  correspond  with  that 
of  the  cylinder,  and  the  velocity  with  which  it  is 
forced  through  the  instrument.  This  jet  thrown 
into  a  cavity  that  has  been  made  as  dry  as  possible 
by  wiping,  soon  makes  a  very  perceptible  change,  the 
walls  of  the  cavity  becoming  whiter  than  before. 
This  we  consider  the  most  desirable  condition  in 
respect  to  dryness,  that  can  be  obtained. 


INTRODUCING   TIIE    FILLING. 


Having,  in  all  the  steps  for  the  preparation  of  the 


INTRODUCING   THE   FILLING.  143 

cavity,  made  thorough  work,  the  next  thing  to  be 
accomplished  is  the  introduction  and  consolidation  of 
the  filling.  The  manner  of  performing  this  part  of 
the  work  will  be  governed  by  the  kind  of  material 
employed,  and  also,  somewhat,  by  the  form  of  the 
particular  material.  Some  materials,  as  gold,  for 
instance,  may  be  used  in  three  or  four  different 
forms,  each  involving  a  principle  peculiar  to  itself; 
and  each  of  these  forms  is  susceptible  of  being  used 
in  different  ways.  It  is  proposed,  in  the  first  place, 
to  describe  the  best  methods  of  introducing  gold,  in 
the  various  forms  in  which  it  is  or  has  been  em- 
ployed, considering  also  the  merits  of  each. 

The  first  method  for  consideration  is  that  of  filling 
with  ordinary  gold  foil.  The  principles  applicable  to 
the  use  of  this  kind  of  foil  also  obtain  in  the  use 
of  foils  of  other  metals.  Gold  is  used  far  more  than 
any  thing  else.  The  common,  and,  indeed,  the 
almost  universal  method  of  using  foil,  at  one  period, 
was  in  the  form  of  a  roll,  or  rope,  as  it  was  sometimes 
called.  By  this  method,  the  foil  is  cut  into  strips 
from  one  third  of  an  inch  to  two  inches  wide,  the 
width  being  governed  somewhat  by  the  size  of  the 
cavity  to  be  filled.  This  strip  is  then  rolled  length- 
wise, forming  a  loose  roll.  The  compactness  of  the 
roll  should  depend  upon  the  size  of  the  points  with 
which  it  is  to  be  condensed  ;  the  smaller  the  points, 
the  more  compact  the  roll  may  be. 


144  FILLINQ    OP   TEETH. 

It  may  be  introduced  either  with  the  condensing 
instrument  or  with  the  plugging  pliers  (improperly 
sometimes  called  plugging  forceps.) 

If  with  the  former,  it  is  taken  up  at  one  end  on 
the  point  of  the  instrument,  and  passed  to  the  bottom 
of  the  cavity ;  and  that  portion  within  the  cavity  is 
pressed  firmly  against  the  wall  where  it  is  desirable 
to  begin  the  rilling.  There  is  no  definite  uniform 
point  in  cavities,  at  which  to  begin  the  introduction 
of  the  gold ;  usually,  however,  in  crown  cavities  of 
the  molars,  at  the  posterior  wall.  At  whatever  point 
the  filling  is  commenced,  the  cavity  should  be  so 
formed  that  it  will  retain  the  first  portion  of  gold  in- 
troduced ;  and  this  may  be  done  by  forming  a  little 
pit  or  groove  for  the  reception  of  the  portion  first  in- 
troduced. This  is  a  particular  that  can  not  with  im- 
punity be  neglected.  The  gold  should  never  change 
its  position  after  it  is  pressed  to  the  wall  of  the 
cavity ;  for  it  can  not  be  adapted  to  any  other  point 
after  it  is  condensed.  The  end  of  the  roll  being 
placed  in  the  cavity,  it  is  seized  far  enough  without 
the  cavity  to  form  a  fold  that  will  extend  to  the  bot- 
tom, and  protrude  from  one  to  two  lines  beyond  the 
border  of  the  orifice.  This  fold  is  pressed  firmly  upon 
the  preceding  portion  of  gold  and  adjacent  walls. 
Thus  fold  after  fold  is  introduced,  passed  to  the  bot- 
tom of  the  cavity,  and,  protruding  from  the  orifice, 
consolidated  firmly,  each  portion  as  it  is  introduced, 


INTRODUCING    THE    FILLING.  145 

being  perfectly  adapted  to  the  walls  of  the  cavity  and 
the  preceding  portion  of  the  filling. 

It  is  important  to  obtain  as  complete  an  adaptation 
of  the  filling  to  the  walls  of  the  cavity  as  possible; 
and  in  order  to  accomplish  this  the  center  should  not 
be  filled  too  rapidly.  The  gold  is  thus  introduced 
fold  after  fold  till  the  cavity  is  full.  When  it  is  filled 
to  two  thirds  of  its  diameter,  the  gold  should  then  be 
adjusted  to  all  the  remaining  walls  of  the  cavity,  and 
the  last  portions  of  gold  introduced  somewhere  in 
the  body  of  the  filling,  certainly  not  next  to  any  wall 
of  the  cavity.  A  more  thorough  adaptation  of  the 
gold  can  be  made  to  the  walls  of  the  cavity,  by  this 
manner  of  arranging  it,  than  by  introducing  the  last 
portion  at  one  side  of  the  cavity.  There  is  less  lia- 
bility of  fracturing  a  frail  tooth  by  placing  the  gold 
on  the  walls  first,  and  terminating  the  introduction 
of  it  at  or  near  the  center  of  the  filling.  It  is  a  very 
common  practice  to  introduce  the  gold  rather  loosely, 
or  without  much  condensing,  and  after  being  intro- 
duced in  this  manner,  to  condense  by  forcing  into  it 
a  wedge-shaped  instrument  at  various  points,  and 
filling  these  perforations  with  small  rolls  of  gold; 
continuing  to  use  the  wedge-shaped  instrument  as 
long  as  it  can  be  forced  into  the  filling.  This  method 
is  by  no  means  as  efficient  as  that  of  condensing  each 
portion  as  it  is  introduced.  By  the  latter  plan  the 
filling  can  be  made  uniformly  dense  from  the  surface 


14G  FILLING    OF    TEliTH. 

to  the  bottom  of  the  filling.  This  can  not  be  done 
by  the  use  of  the  wedge-shaped  instrument ;  it  will 
compress  most  at  its  largest  diameter,  that  is,  at  the 
surface  of  the  plug. 

In  no  filling,  even  when  the  walls  of  the  cavity  are 
parallel,  will  a  uniform  density  throughout  be  ob- 
tained by  perforating  with  the  wedge.  The  filling 
would  be  most  dense  at  the  surface,  and  less  so  the 
farther  into  the  filling  we  go.  This  method  is  objec- 
tionable for  condensing  the  fillings  on  the  masticating 
surfaces  of  the  molars ;  for  in  the  act  of  mastication 
the  inner  portion  would  yield,  and  the  surface  of  the 
filling  would  be  crowded  down  into  the  cavity,  and 
the  dentine  within  the  orifice  become  exposed  and 
decay.  In  proximal  fillings  this  objection  would  not 
have  the  same  force.  In  forcing  an  instrument  of  a 
wedge  form  into  a  filling  with  sufficient  force  to  con- 
dense the  mass,  there  would  be  great  danger  of  break- 
ing a  weak  wall  of  the  cavity.  The  principal  pressure 
is  lateral,  and  would  consequently  come  upon  the 
side  of  the  tooth. 

In  crown  cavities  of  the  molars  where  there  is  any 
considerable  inward  expansion  of  the  cavity,  that 
method  of  condensing  would  be  wholly  inefficient ;  it 
would  not  render  the  inner  portion  dense  enough  to 
support  the  surface  of  the  plug,  and  it  would  be 
forced  down,  and  necessarily  be  loose.  In  filling  the 
proximal  cavities  of  the  incisors,  it  is  very  objection- 


INTRODUCING    THE    FILLING.  147 

able  on  account  of  the  great  liability  of  breaking  the 
inner  and  outer  walls,  which  are  usually  quite  thin. 

In  preparing  the  foil  for  filling,  sonic  operators  tear 
off  the  foil  in  irregular  pieces,  and  make  into  little 
balls  or  pellets,  round  and  loosely  rolled,  correspond- 
ing in  size  with  the  cavity  to  be  filled.  These  pellets 
are  placed  in  the  bottom,  if  a  crown  cavity,  and  at 
one  side,  if  a  proximal  cavity,  and  condensed  with  a 
sharp-pointed  instrument,  attaching  one  pellet  to  an 
other  till  the  cavity  is  full.  This  mode  is  not  so 
good  as  that  previously  referred  to,  unless  the  gold  is 
in  a  condition  to  weld  perfectly;  there  is  no  con- 
tinuous portion  from  the  bottom  to  the  orifice  of  the 
cavity ;  and  the  outer  portions  are  liable  to  become 
detached.  Both  of  these  methods  of  arranging  the 
gold  are  objectionable  in  one  particular,  namely,  the 
irregularity  of  the  leaves  or  laminse  of  the  foil ;  these 
are  placed  in  the  cavity  without  any  regard  to  regu- 
larit}',  and  the  consequence  is,  that  without  very 
great  care,  far  less  gold  will  be  introduced  than  by 
some  other  arrangement.  Far  more  difficulty  is  ex- 
perienced in  obtaining  a  uniform  and  equal  density 
than  when  the  laminae  are  placed  smoothly  together. 

An  other  method  of  preparing  the  foil  is  to  fold  it 
into  from  four  to  twelve  thicknesses,  then  cut  off 
strips  in  width  corresponding  to  the  diameter  of  the 
cavity.  The  strip  thus  prepared  is  introduced  in  the 
same  manner  as  the  roll,  except  that  as  each  fold  is 


148  FILLING    OF    TEETH. 

inserted,  it  is  placed  smoothly  against  the  preceding 
portion,  and  kept  smooth  and  free  from  wrinkles. 
By  this  arrangement  very  little  force  is  required  to 
bring  the  folds  in  perfect  contact.  Some  care  and 
skill  will  be  necessary  to  bring  the  instrument  to 
bear  upon  the  whole  surface  of  the  fold.  More  gold 
can  be  put  into  a  cavity  in  this  manner  than  in  rolls 
or  pellets,  unless  these  are  used  in  very  small  por- 
tions, and  condensed  very  perfectly  as  they  are  put  in. 

CLOCK    FILLING. 

An  other  and  in  some  respects  far  preferable 
method,  is  filling  with  blocks.  Some  of  the  advant- 
ages of  this  method  over  that  just  described,  are  the 
following  :  the  filling  can  be  introduced  far  more 
rapidly;  and  the  lamina?,  or  leaves  of  foil  take  a 
more  perfect  position  in  the  cavity,  and  consequently 
the  structure  of  the  filling  is  better.  The  form  of 
the  cavity  should  be  much  the  same  as  that  for  any 
other  method  of  filling;  there  should  be  some  retain- 
ing point  so  situated  that  the  first  block,  or  blocks, 
can  be  fixed  firmly  in  place,  so  that  there  will  be 
no  liability  of  loosening  during  the  subsequent  part 
of  the  process.  It  is  important  to  have  such  an  ar- 
rangement, as  otherwise  it  would  be  necessary  to 
employ  an  instrument  in  the  left  hand  to  retain  the 
first  blocks  in  situation,  till  enough  were  introduced 


BLOCK   FILLING.  149 

to   bind   the   whole   by  pressure   upon   two  opposite 
points  in  the  cavity. 

Forming  Blocks. — For  forming  blocks,  use  any 
number  of  foil  that  may  be  desired,  usually  No.  4  or 
6,  and  either  lay  four  to  six  sheets  together,  or  fold  a 
single  sheet  into  that  number  of  thicknesses;  then 
cut  off,  from  the  sheets  thus  prepared,  strips  about 
one  third  to  one  fourth  wider  than  the  depth  of  the 
cavity  to  be  filled ;  which  are  then  rolled,  on  a  small 
three-sided  or  four-sided  broach — the  three-sided  is 
better;  and  this  instrument  should  be  very  small;  no 
larger,  indeed,  than  is  indispensable  for  strength. 
Its  sides  should  be  perfectly  smooth,  and  its  angles 
sharp ;  ordinarily  it  should  not  taper,  or  at  least  very 
slightly.  For  forming  the  conical  blocks,  some  prefer 
the  tapered  broaches,  but  they  can  be  as  well  made 
on  the  parallel-sided  instruments.  The  strip  being- 
taken  between  the  thumb  and  the  index  finger,  is 
rolled  on  the  broach  equally,  till  the  block  or  cylin- 
der is  large  enough,  when  the  strip  is  broken  off. 
The  sizes  of  the  principal  part  of  the  blocks  should 
correspond  with  the  sizes  of  the  cavities  to  be  filled. 
Different  sizes  and  forms  will  be  required  in  almost 
all  cases.  Relatively  large  cylinders  may  be  em- 
ployed for  the  principal  part  of  the  filling.  If  the 
walls  of  the  cavity  are  parallel,  almost  all  the  blocks 
may  be  truly  cylindrical;  but  if  there  is  an  under- 
dipping  of  one  or  more  of  the  walls,  the  blocks  ad- 


150  FILLING    OF    TEETH. 

justed  to  that  particular  part  should  be  cone-shaped, 
corresponding  to  that  underdipping.  A  number  of 
small  graduated  cone-shaped  blocks,  of  different  de- 
grees of  density,  will  be  required  for  completing  each 
filling ;  as  the  aperture  becomes  smaller,  smaller 
blocks  will  be  needed.  The  cone-shaped  blocks  are 
formed,  by  gradually  running  the  strip  back  from  the 
point  of  the  instrument  as  it  is  wound  on ;  greater  or 
smaller  taper  can  be  given  to  it,  as  the  strip  is  run 
less  or  more  rapidly  back  from  the  point.  The 
density  of  the  block  can  be  regulated  by  the  firmness 
with  which  the  strip  is  held  between  the  thumb  and 
finger ;  upon  which  it  is  well  to  have  a  fine  silk  or 
India-rubber  covering  to  protect  the  gold  from  the 
perspiration  of  the  hand.  There  are  other  methods 
of  forming  blocks.  They  may  be  made  square,  by 
making  a  great  number  of  folds — fifteen  to  thirty — 
and  from  this,  cutting  strips  as  before  directed,  and 
then  from  these  heavy  strips  cutting  off  the  blocks  of 
the  desired  size,  which  will  then  be  flat  or  nearly 
square.  In  one  respect  these  blocks  are  objection- 
able :  the  edges,  when  they  have  been  cut  off,  are 
rendered  dense  by  the  action  of  the  shears,  so  that 
they  do  not  possess  the  uniform  density  or  consist- 
ence of  the  rolled  blocks,  and  it  is  impossible  to  adapt 
them  as  perfectly  to  the  walls  of  the  cavity,  or  to  one 
an  other.  This  objection,  however,  may  be  obviated 
by  cutting  off  the  blocks  with  a  very  fine  saw. 


BLOCK   FILLING.  151 

An  other  method  of  forming  blocks,  first  employed 
by  Dr.  Blakesley,  is  to  roll  a  sheet  of  No.  5  foil  into  a 
rope,  and  cut  off  from  it  blocks  corresponding  with 
the  size  of  the  cavity  to  be  filled.  These  are  liable 
to  the  same  objection  as  those  last  mentioned,  the 
shears  hardening  them,  when  they  are  cut  off.  They 
are  subject  to  the  additional  objection,  that  the  folds 
of  foil  are  not  as  regular  as  by  either  of  the  other 
methods.  But  by  proper  manipulation,  with  the  gold 
prepared  in  this  manner,  superior  fillings  may  be 
made.  The  cavity  formed,  and  the  blocks  prepared, 
the  next  step  is  their  introduction. 

Introducing  the  Blocks. — For  placing  the  gold  into 
the  cavity  the  plugging  pliers  will  be  required;  the 
points  of  which  should  be  curved,  so  as  to  make  the 
most  perfect  approach  to  the  cavity.  The  points, 
too,  if  properly  formed,  may  be  used  for  condensing 
the  blocks.  All  things  being  ready,  with  suitable 
napkins  and  guards  for  the  protection  of  the  cavity 
against  the  encroachment  of  moisture  from  the  saliva 
and  breath,  the  fingers  of  the  left  hand  should  press 
upon  the  napkin,  and  also  hold  away  the  soft  parts. 
If  there  is  a  very  acute  angle,  a  small  block  should 
be  first  introduced  with  the  pliers  into  the  proper 
position,  one  end  upon  the  bottom  of  the  cavity,  and 
the  other  protruding  from  the  orifice,  and  pressure 
then  be  made  upon  it  to  consolidate  it,  and  force  it 
into  its  position  against  the  wall  of  the  cavity.     This 


152  FILLING    OF    TEETH 

may  be  done  with  the  pliers,  or  probably  better  with 
an  instrument  formed  for  the  purpose.  The  part  of 
the  instrument  brought  to  bear  upon  the  gold  should 
be  roughened  either  longitudinally  or  transversely,  so 
that  a  proper  surface  may  be  left  for  the  reception  of 
the  succeeding  portions.  The  largest  blocks  are  then 
introduced  and  consolidated  successively  as  described. 
The  end  of  each  left  protruding  till  the  cavity  is 
filled,  each  portion  as  it  is  introduced,  should  be  per- 
fectly condensed.  The  gold  should  be  filled  in  faster 
at  the  sides  of  the  cavity  than  in  the  center,  thus 
being  disposed  round  the  walls  till  it  meets  at  a  point 
opposite  the  place  of  beginning;  and  thus  it  is  adapted 
to  all  the  walls  of  the  cavity  before  this  is  entirely 
filled,  the  last  portions  being  introduced  somewhere 
near  the  center  of  the  filling.  As  the  cavity  dimin- 
ishes by  the  introduction  of  the  gold,  the  small  and 
more  dense  blocks  will  be  required  ;  which  should  be 
forced  in  and  condensed,  by  crowding  an  instrument 
down  against  the  side  of  the  cone.  Some  operators 
terminate  the  filling  against  the  wall  of  the  cavity, 
forcing  down  the  blocks  and  compressing,  as  above, 
till  it  is  full.  By  this  method  there  is  danger  of 
fracturing  the  tooth,  breaking  down  the  wall  of  the 
cavity,  when  the  filling  is  terminated.  An  other 
method  is  to  fill  up  the  cavity  principally  with 
blocks,  and  to  put  in  the  last  part  of  the  filling  in 
the   strip,  fitted  in   from   the   bottom  to  the  orifice. 


BLOCK    PILLING.  163 

The  objection  to  this  method  is,  that  unless  adhesive 
foil  is  employed,  the  portion  inserted  in  the  strip  is 
liable  to  be  displaced,  and  in  this  way  the  whole 
filling  to  become  destroyed. 

An  other  method  of  arranging  this  kind  of  filling, 
particularly  when  the  bottom  of  the  cavity  is  ir- 
regular, is  to  make  a  large,  flat  pellet,  press  it  firmly 
into  the  bottom,  and  set  the  blocks  upon  this  for  a 
foundation.  By  this  method  there  is  a  more  perfect 
adaptation  of  the  gold  to  the  bottom  of  the  cavity, 
than  by  placing  the  ends  of  the  blocks  down  upon  an 
uneven  surface.  After  the  gold  is  all  introduced,  a 
small-pointed  plugger  must  be  passed  all  over  the 
surface,  to  consolidate  the  protruding  portions  and 
form  a  surface  to  the  filling.  These  protruding  por- 
tions should  be  sufficient  to  make  the  surface  per- 
fectly flush  with  the  border  of  the  cavity  ;  for  a  de- 
pression here  is  fatal  to  a  complete  finish.  After  the 
surface  is  condensed  with  the  fine  and  large  points, 
it  may  be  rubbed  down  with  an  instrument  serrated 
upon  the  side,  and  afterward  with  the  coarse  file,  and 
then  with  the  fine,  etc. 

Dr.  Badger  describes  a  method  of  filling  a  small 
cavity  on  the  posterior  proximal  portion  of  a  second 
molar,  the  third  molar  gone.  The  cavity  is  formed 
with  a  bur  drill.  A  cylinder  is  then  formed  in  the 
usual  manner,  and  forced  through  a  series  of  holes  in 
a  drawplate,  down  to  the  size  of  the   bur  with  which 


154  FILLING    OF    TEETH. 

the  cavity  is  formed.  The  block  is  thus  rendered 
quite  dense.  The  cavity  is  then  dried,  and  the  block 
forced  into  it,  which  it  exactly  fit;s,  protruding  a  little 
from  the  orifice.  This  block  is  pierced  in  the  center 
with  a  sharp  instrument,  and  a  small  dense  roll  forced 
into  it ;  and  all  is  then  condensed  and  finished  in  the 
usual  manner. 

Pellets.  —  Pellets  made  by  rolling  fragments  or 
pieces  of  foil  between  the  thumb  and  fingers,  are  used 
by  some  operators,  and  with  them  they  profess  to 
make  as  good  filling  as  by  any  other  method.  They 
are  made  of  various  sizes,  and  packed  into  the  cavity 
with  sharp-pointed  or  serrate-pointed  instruments. 
The  pieces  may  thus  be  very  solidly  worked  to- 
gether, and  a  good  filling  made,  provided  the  pellets 
are  not  too  large ;  they  should  be  small  enough  to 
permit  the  point  or  points  to  work  through  them  into 
the  preceding  portions.  Some  operators  use  pellets 
and  crystal  gold  together.  This  may  do  very  well, 
if  the  adhesive  property  of  the  gold  is  employed;  but 
in  that  case,  either  form  of  the  material  would  answer 
alone.  There  can  not  be  as  much  gold  put  in  by 
pellets  as  by  blocks  well  adjusted. 

Adhesive  Foil. — By  this  we  understand  that  condi- 
tion of  gold  foil  in  which  the  leaves  unite  very  readily 
and  very  firmly  togther.  This  property  of  cohesion 
is  possessed,  in  the  greatest  degree,  by  properly  manu- 
factured foil,  immediately  after  annealing.     Not  that 


BLOCK    FILLING.  155 

annealing  imparts  any  new  property  to  the  gold,  but 
it  removes  obstacles  to  the  manifestation  of  a  principle 
possessed  by  all  gold  under  favorable  circumstances. 
It  is  now  about  four  years  since  this  property  was 
first  employed  in  gold  foil  for  filling  teeth.  To  Dr. 
R.  Arthur  is  due  the  credit  of  first  directing  the 
attention  of  the  profession  to  it.  He  not  only  did 
this,  but  he  entered  most  fully  into  the  details  of  the 
manipulations,  instruments,  etc.,  pertaining  to  this 
mode  of  operation.  Almost  all  recently  prepared 
gold  foil  possesses  this  property  to  a  greater  or  less 
degree ;  there  are  methods  of  preparing  it,  however, 
by  which  it  possesses  it  most  fully ;  all  recently 
annealed  foil  is  adhesive.  If  the  foil  is  adhesive 
when  we  wish  to  use  it,  nothing  further  is  required 
in  the  way  of  preparation.  But  if  it  is  not  adhesive 
— as  almost  all  foil  is  not,  especially  if  it  has  been 
exposed  to  the  influence  of  the  atmosphere — it  will 
require  to  be  made  so  by  some  process :  there  are 
two,  either  of  which  will  perfectly  accomplish  the 
object. 

The  one  most  frequently  employed,  is  that  of  heat- 
ing the  gold,  either  in  the  sheet,  in  the  roll,  or  in 
fragments,  over  the  flame  of  a  spirit-lamp,  almost  or 
quite  to  a  red  heat;  if  in  the  sheet,  it  should  be  laid 
upon  a  piece  of  wire  gauze,  and  passed  over  the  flame 
of  the  lamp  for  a  moment  or  two ;  if  in  the  roll,  it 
may  be   taken   in   the   center  with   fine    pliers   and 


156  FILLING    OF    TEETH. 

passed  rapidly  through  the  flame ;  if  in  small  frag- 
ments or  pellets,  placed  upon  a  piece  of  charcoal  and 
a  light  flame  thrown  upon  them  with  a  blowpipe. 
The  other  method  is  that  adopted  by  Dr.  Coates. 
Into  a  little  platinum  pan,  large  enough  to  hold  an 
unfolded  sheet  of  foil,  are  put  one  or  two  gills  of  rain 
water,  to  which  are  added  about  forty  drops  of  sul- 
phuric acid;  and  in  this  liquid  the  foil  is  boiled  a 
few  moments  over  the  flame  of  a  spirit-lamp.  The 
acid  removes  all  foreign  substances  from  the  surface 
of  the  gold.  Eemove  it  from  the  boiling  liquid,  and 
in  a  moment  it  is  dry  and  ready  for  use,  and  will  be 
most  thoroughly  adhesive. 

There  are  different  methods  of  using  gold  in  this 
condition ;  but  in  general  the  cavity  should  be  formed 
about  as  for  the  other  methods  of  filling,  except  that 
to  retain  the  first  piece,  there  should  be  two  or  three 
small  pits  or  holes  made  for  retaining  points  in  the 
most  available  position.  The  first  portion  of  gold 
should  be  a  little  pellet ;  this  forced  into  these  re- 
taining points,  serves  as  a  foundation  for  the  remain- 
ing portion  of  the  filling.  Dr.  Arthur's  method  is, 
then,  to  tear  off  fragments  from  the  sheet,  and  pass  it 
into  the  cavity  without  folding  up,  and  condense  it 
with  a  fine  serrate-pointed  instrument,  so  that  it  not 
only  unites  by  cohesion,  but  it  is  worked  into  the 
surface  of  the  preceding  portion  of  gold;  and  in  this 
manner  portion  after  portion  is  introduced  and  con- 


BLOCK    FILLING.  157 

densed,  until  the  cavity  is  full.  The  filling  may  be 
commenced  in  any  part  of  the  cavity  that  is  most 
convenient;  in  many,  as  in  crown  cavities  of  the 
molars,  at  the  bottom,  and  filled  to  the  orifice.  In 
putting  in  the  gold,  it  should,  during  its  introduction, 
be  kept  fuller  about  the  walls  of  the  cavity  than  in 
the  center ;  by  this  means  the  adaptation  will  be 
most  perfect  to  the  walls,  and  there  will  be  no  lia- 
bility of  clogging  up  the  center.  The  gold  may  thus 
be  built  up  to  any  desired  extent  if  the  filling  is  kept 
dry ;  moisture  is  fatal  to  its  adhesiveness. 

Others  use  the  adhesive  gold  in  a  different  manner. 
To  Dr.  Blakesley  belongs  the  honor  of  first  detail- 
ing the  following  plan :  The  sheet  of  gold  may  be 
folded  or  not  at  the  pleasure  of  the  operator,  and 
then  each  sheet  cut  into  from  two  to  six  strips,  and 
these  formed  into  a  loose  roll  between  the  thumb  and 
fingers.  It  may  now  be  passed  rapidly  through  the 
flame  of  a  spirit-lamp  to  remove  any  foreign  sub- 
stance that  may  be  upon  it;  when  it  is  cut  into  little 
blocks  or  pellets  of  various  sizes;  these  to  be  regu- 
lated by  the  size  of  the  roll  and  the  amount  cut  off. 
For  the  introduction  of  the  gold  thus  prepared,  about 
three  sizes  of  serrate-pointed  instruments  are  re- 
quired, those  having  fine  points  being  preferable.  As 
to  the  sizes  of  these  points,  Dr.  Blakesley  remarks, 
"they  will  just  enter,  respectively,  No.  22,  24,  and 
26  of  the  wiregauge."     A  larger  than  either  of  these, 


158  FILLING    OF    TEliTII. 

however,  is  desirable  for  many  cases.  As  before,  the 
filling  may  be  commenced  at  the  bottom  of  the  cavity 
or  at  one  side,  if  desirable,  with  a  pellet  sufficiently 
large  to  be  set  firmly  into  the  retaining  points.  Then 
take  up  the  small  pellets  or  blocks  upon  the  point  of 
the  plugging  instrument,  and  place  them  exactly  in 
the  desired  position,  and  consolidate  them  perfectly, 
building  up  next  to  the  wall  all  around  higher  than 
the  center  with  the  smaller  pieces,  filling  up  the  little 
corners  and  interstices ;  for  which  manipulation  the 
smaller  points  will  be  required.  The  gold  is  then 
packed  in  till  the  cavity  is  full,  when  it  is  finished  as 
usual.  An  other  method  is  to  tear  off  fragments  from 
the  sheet,  and  roll  these  up  into  round  pellets,  and 
fill  with  these,  with  the  same  instruments  and  upon 
the  same  principle  as  above  described.  But  by  this 
method  it  is  difficult  to  make  a  perfect  filling ;  the 
gold  is  liable  to  clog  in  the  cavity,  and  fail  in  adapta- 
tion. 

Adhesive  gold  must  be  consolidated  as  it  is  intro- 
duced ;  for  after  a  cavity  is  full,  it  is  very  difficult 
then  to  condense  it  any  more,  even  though  the  con- 
solidation is  but  partial ;  and  much  more  is  this  true 
of  nonadhesive  foil. 


CRYSTAL  GOLD. 


The    form   of  the   cavity   for   crystal-gold  filling. 


CRYSTAL    GOLD.  159 

should  be  much  the  same  us  that  described  for  other 
fillings,  except  that  the  same  care  is  not  necessary  for 
special  retaining  points ;  for  the  first  portion  of  gold 
that  is  introduced  into  the  cavity,  as  good  crystal 
gold,  will  attach  to  the  wall  of  the  cavity  without 
any  such  special  retaining  points  :  such  a  form  should 
be  given  as  to  secure  the  first  piece  firmly  in  place. 
The  gold  should  be  cut  or  broken  into  pieces  cor- 
responding in  size  to  the  cavity,  so  that  they  will 
enter  freely  into  it. 

The  filling  may  be  commenced  upon  the  bottom  of 
the  cavity,  or  upon  one  of  its  sides ;  such  a  point 
always  being  selected  as  will  most  effectually  retain 
the  gold  in  place.  The  pluggers  should  be  of  various 
sizes — the  first  one  as  large  as  can  be  used  in  the 
cavity,  and  smaller  ones  for  condensing  more  thor- 
oughly ;  and  all  should  be  serrated  with  from  two  to 
six  sharp  points,  usually  four.  The  blocks  may  be 
taken  up  on  the  points  of  the  plugger,  and  passed  to 
their  proper  position  in  the  cavity,  and  there  con- 
densed. The  sharp,  serrated  point  leaves  the  surface 
in  good  condition  for  the  reception  of  the  next  piece. 
The  gold  should  be  packed  to  the  walls  of  the  cavity 
a  little  in  advance  of  the  center,  so  that  its  adapta- 
tion may  be  more  complete.  In  this  manner,  the 
filling  is  built  up  as  much  as  is  desirable,  if  it  is  kept 
dry — and  unless  it  is,  all  cohesion  is  lost. 

The  gold,  after  it  is  cut  up,  is  put  on  a  piece  of 


160  FILLING    OF    TEETH. 

charcoal,  and  annealed  with  a  blowpipe,  by  the  flame 
of  a  spirit-lamp,  carefully,  so  as  not  to  fuse  any  of  the 
particles,  as  that  would  impair  their  facility  of  cohe- 
sion in  this  process :  very  minute  portions  are  often 
required  to  fill  up  small  interstices,  or  notches. 

In  crown  cavities,  the  filling  should  begin  at  the 
bottom ;  in  proximal  cavities,  at  the  cervical  wall. 
By  introducing  the  gold  in  this  manner,  the  pressure 
is  made  on  a  line  with  the  axis  of  the  tooth ;  which 
is  an  important  consideration.  The  surface  of  the 
filling  should  always  be  convex,  though  in  some 
cases  but  slightly,  except  where  the  antagonism  of 
the  teeth  prevents,  as  in  the  crown  fillings  of  the 
molars — in  which  case,  it  should  be  adapted  for  the 
reception  of  the  opposing  tooth.  Proximal  fillings 
should  usually  be  a  little  convex ;  yet  many  good 
fillings  of  this  class  are  effected  with  a  surface  per- 
fectly plain  with  the  borders  of  the  cavity.  The 
borders  of  the  filling,  however,  are  better  protected 
when  it  is  somewhat  convex. 

Crystal  gold,  of  perfect  character,  presents  to  the 
walls  of  the  cavity  a  surface  better  calculated  to  be 
retained,  than  foil  in  any  of  its  forms ;  though  adhes- 
ive foil  possesses  this  advantage  to  a  greater  extent 
than  foil  in  any  other  condition.  The  points  and 
edges  of  the  crystals  are  brought  in  contact  with  the 
walls,  and  made  to  take  a  firmer  hold  upon  the 
dentine. 


CRYSTAL   GOLD.  161 

In  forming  crystal  gold  into  a  solid  mass,  two  prin- 
ciples are  operative  :  cohesion  acts  upon  it  as  poten- 
tial^' as  upon  gold  in  any  other  form,  and,  in  addi- 
tion, there  is  the  interlacing,  or  locking,  of  the 
crystals  with  one  an  other;  so  that  a  more  perfect 
union  of  the  different  portions  of  which  a  filling  is 
composed,  is  obtained  with  crystal  gold  than  with 
foil.  Yet  good  adhesive  foil,  when  thoroughly 
worked  in,  attains  almost  the  same  condition.  With 
perfect  crystal  gold,  however,  some  advantages  may 
be  secured,  that  can  not  be  had  with  foil.  The  gold 
will  be  retained  in  a  cavity  that  will  not  retain  a  foil 
filling;  it  is  more  easily  formed  into  a  coherent  mass; 
it  can  be  built  out  with  more  ease ;  cavities  can  be 
filled  with  it  that  can  not  be  filled  with  foil  at  all ; 
and  a  filling  of  it  is  susceptible  of  a  far  better  finish, 
with  the  same  labor,  than  a  filling  of  foil. 

It  is  important  to  keep  the  gold  perfectly  free  from 
moisture,  while  being  introduced  and  consolidated ; 
for  moisture  instantly  destroys  its  cohesive  property. 
And  the  more  complete  the  exclusion  of  moisture 
from  the  cavity,  during  the  process,  the  better  for 
the  success  of  the  operation.  The  surface  of  every 
filling  should  be  consolidated  for  finishing,  before  it  is 
allowed  to  become  moist ;  for,  whenever  it  becomes 
saturated  with  moisture  before  consolidation,  it  is 
impossible  to  make  a  perfect  finish.  There  should 
always   be   gold  enough  superadded  to  insure  this; 


162  FILLING    OF    TEETH. 

and  the  consolidation  of  the  last  surface  should  be 
effected  with  a  rough-ended,  not  serrated,  instrument. 

FINISHING    FILLINGS. 

The  method  of  finishing  a  filling,  and  the  manipu- 
lation, will  depend  somewhat  on  the  locality  of  the 
cavity.  When  this  has  been  completely  filled,  and 
the  filling  thoroughly  consolidated  over  all  the  sur- 
face, and  especially  all  round  its  border,  the  file 
should  be  applied  to  dress  off  any  projecting  portion, 
and  render  the  filling  smooth.  In  consolidating  the 
surface,  an  instrument  should  be  used,  that  would  not 
pit  it,  and  the  file  should  remove  all  indentations. 
The  work  of  the  file,  however,  should  be  but  partially 
peformed  at  first,  and  the  surface  consolidated  again, 
with  a  square-pointed  instrument.  To  obtain  the 
most  perfect  finish,  the  surface  should  be  brought  to 
a  uniform  consistence ;  and  this  condition  can  not  be 
reached  by  the  use  of  sharp-pointed  instruments,  nor 
fully  by  that  of  the  blunt  plugger  at  the  first  effort, 
but  by  the  alternate  use  of  the  file,  the  blunt  con- 
denser, and  the  burnisher.  A  coarse  file  should  be 
employed  in  this  part  of  the  process ;  but  when  the 
filling  is  dressed  sufficiently,  and  in  good  condition, 
the  fine  file  should  be  used,  alternately  with  the 
burnisher,  till  a  perfectly  uniform  surface  is  obtained. 
In  all  cases,  after  the  file  lias  been  applied,  the  plug 


FINISHING    FILLINGS.  163 

should  be  washed  off  with  a  brush,  to  remove  all 
detached  pieces  of  gold,  before  the  burnisher  is  put 
upon  it;  and  after  the  fine  file  and  burnisher,  the 
Scotch-  or  Arkansas-stone  or  very  fine  pumice  should 
be  employed  to  remove  the  filemarks.  The  pumice 
may  be  applied  with  water  on  a  strip  of  chamois  skin, 
a  piece  of  linen  tape,  or  a  stick  of  soft  wood — the 
latter  being  the  most  convenient,  as  it  can  be  used 
with  one  hand  and  shaped  to  suit  any  place  or 
position. 

After  the  stone  or  the  pumice  has  accomplished  its 
work,  and  the  filling  has  been  thoroughly  washed,  a 
fine  burnisher,  with  a  solution  of  castile  soap,  is  em- 
ployed to  give  the  finish.  The  burnisher  should  be 
of  the  best  cast  steel,  and  of  high  temper  and  fine 
polish.  Considerable  skill  is  requisite  to  give  the 
best  effect  with  the  burnisher;  it  should  pass 
smoothly  and  gently  over  the  surface,  throughout  its 
whole  extent,  and  in  parallel  lines,  with  a  pressure 
neither  too  light  nor  too  heavy.  It  should  also  be 
applied  very  thoroughly  upon  any  portion  of  the 
tooth  about  the  border  of  the  filling,  that  may  have 
been  cut  by  the  file  or  any  other  instrument.  In- 
deed, quite  as  much,  if  not  more,  care  should  be  exer- 
cised upon  this  as  upon  the  plug  itself:  it  should  be 
polished  as  smooth  as  the  enamel,  if  possible;  for  the 
more  nearly  perfect  it  is  in  this  respect,  the  better 
will  it  resist  the  action  of  deleterious  agents. 


164  FILLING    OF    TEETH. 

This  method  of  finishing  gives  to  the  filling  a  per- 
fect metallic  luster;  which,  under  some  circum- 
stances, might  be  objectionable.  Two  other  methods 
are  in  use  :  after  the  burnisher  has  been  applied,  as 
above,  the  buff  or  tape,  with  rouge,  may  be  employed, 
by  passing  it  rapidly  over  the  filling  till  the  metallic 
luster  is  destroyed,  or  deadened,  so  as  not  to  reflect 
the  light  as  before,  thus  leaving  a  very  desirable 
finish ;  and  the  other  method  is,  to  stipple  over  the 
surface  of  the  burnished  filling  with  the  end  of  a 
piece  of  hard  wood — sandal  wood  is  recommended — 
charged  with  finely  pulverized  pumice.  This  gives  a 
beautiful,  velvetlike  surface,  and  is  fine  for  fillings  in 
the  anterior  portion  of  the  mouth,  where  they  are 
exposed  to  view.  Rotten-stone,  applied  either  with 
the  buff  or  with  hard  wood,  imparts  a  finish  which, 
though  a  little  different,  is  finer  than  any  of  the 
others. 

For  finishing,  some  operators  prefer  to  cut  and 
polish,  instead  of  filing  and  burnishing.  But  neither 
so  good  nor  so  fine  a  finish  can  be  effected  in  this 
way,  and  it  is  probable  that  economy  of  time  and 
labor,  especially  the  latter,  suggested  the  method. 
In  all  cases,  the  filling  should  have  a  distinct  and 
definite  margin :  the  gold  should  be  trimmed  off  quite 
up  to  the  border  of  the  cavity,  by  passing  round  it  a 
small,  sharp  instrument,  so  as  to  detect  and  pare 
down    any   portion    that   might   overlap   the    tooth. 


FINISHING    FILLINGS.  165 

For,  if  overlapping  portions  are  permitted  to  remain, 
foreign  substances  will  lodge  beneath,  and  induce 
decay.  Neglect  in  this  particular  has  occasioned  the 
loss  of  thousands  of  teeth  that  otherwise  might  have 
been  saved. 

The  subject  of  finishing  is  almost  entirely  over- 
looked by  very  many  operators  ;  but  by  the  neat  and 
skillful  it  is  esteemed  of  sufficient  importance  to  de- 
mand as  great  labor  and  pains  as  any  other  part  of 
the  operation. 


CHAPTER  VII. 

CLASSIFICATION    OF    DECAYED    CAVITIES. 

The  following  classification  of  decayed  cavities  in 
the  teeth,  though  from  the  very  nature  of  the  sub- 
ject imperfect,  will  be  found  sufficiently  accurate  for 
the  purposes  of  the  dental  student  and  scientifician. 
It  is  based  primarily  on  the  position  of  the  cavities, 
and  secondarily  on  the  extent  of  the  decay ;  the 
classes  having  reference  to  the  former,  and  the  modi- 
fications to  the  latter.  The  classes  are  numbered  ac- 
cording to  the  accessibility  of  the  cavities,  beginning 
with  those  most  easily  approached  and  operated 
upon ;  and  the  modifications  according  to  the  extent 
of  the  decay,  beginning  with  the  smallest  and  sim- 
plest in  form. 

First  Class. — Central  crown  cavities  in  the  molars 
and  bicuspids. 

1st  Mod. — Extension  of  the  decay  along  one  or 
more  fissures. 

2d  Mod. — Two  decays  in  close  proximity  on  the 
same  crown,  which  may  be  formed  into  one  cavity 
for  fillino:. 


CLASSIFICATION    OF    DECAYED    CAVITIES.  167 

Second  Class. — Cavities  in  the  buccal  and  palatal 
surfaces  of  the  molars  and  bicuspids,  and  in  the  labial 
and  palatal  surfaces  of  the  canines  and  incisors. 

1st  Mod.  —  Extension  of  the  decay  beneath  the 
margin  of  the  gums. 

2d  Mod. — Extension  of  the  decay  so  as  to  involve  a 
portion  of  the  crown  surface. 

Third  Class. — Anterior  proximal  cavities  of  the 
bicuspids  and  molars. 

1st  Mod. — Extension  of  the  decay  toward  the  neck 
of  the  tooth,  beyond  the  termination  of  the  enamel. 

2d  Mod. — Extension  of  the  decay  so  as  to  involve 
a  portion  of  the  grinding  or  crown  surface. 

Fourth  Class. — Proximal  cavities  of  the  incisors 
and  canines. 

1st  Mud. — Palatal  wall  of  the  cavity  broken  away. 

2d  Mod. — Labial  wall  broken  away. 

3c/  Mod. — The  cavity  at  the  point  of  the  tooth,  ter- 
minating at  the  surface. 

Ath  Mod. — The  borders  of  the  cavity  very  thin,  and 
the  lateral  walls  inclining  to  the  center. 

Fifth  Class. — Posterior  proximal  cavities  of  the 
molars  and  bicuspids. 

Modifications  same  as  those  of  third  class. 

Modifications  common  to  all  the  classes  : — 1st.  Su- 
perficial cavity  and  a  large  orifice.  2d.  Deep  cavity 
and  a  small  orifice. 

Modification  common    to  classes    three,  four,  and 


168  CLASSIFICATION    OF    DECAYED    CAVITIES. 

five  : — Transverse  extension  of  the  decay  round  one 
or  more  angles  of  the  tooth,  under  the  termination  of 
the  enamel. 


FILLING    BY    CLASSES    AND    MODIFICATIONS. 

First  Class. — Central  cavities  of  the  molars  and 
bicuspids.  These  decays  always  begin  in  the  depres- 
sions on  the  masticatory  surfaces,  which  are  vulner- 
able points,  the  enamel-membrane  folding  together 
here,  and  often  being  found  imperfectly  united,  so 
that  an  opening  is  left  into  the  dentine  :  besides,  these 
indentations  afford  lodgment  for  foreign  substances, 
which  may  be  forced  into  them  in  the  process  of 
mastication,  and  there  retained,  till,  becoming 
vitiated,  they  produce  decay.  Examine  carefully  the 
extent  and  the  nature  of  the  decay,  and  the  form  of 
the  cavity,  which,  of  course,  greatly  varies.  In  some 
cases,  the  cavity  is  found  with  a  small  diameter  and 
a  comparatively  great  depth,  the  diameter  at  the 
orifice  being  the  same  as  within  ;  in  others,  with  a  dia- 
meter larger  at  the  orifice — as  occurs  in  cases  in  which 
a  considerable  portion  of  the  enamel  at  the  depres- 
sions on  the  crown  is  imperfect.  In  the  majority  of 
instances,  however,  the  diameter  of  the  cavity  is 
much  larger  within  than  at  the  orifice.  Sometimes  the 
decay  is  found  to  burrow  directly  beneath  the  enamel 
more  rapidly  than  at  any  other  point;  as  where  there 


FILLING    BY    CLASSES   AND    MODIFICATIONS.  IG',1 

is  an  imperfect  union  between  the  enamel  and  the 
dentine.  In  other  instances,  the  cavity  seems  to 
expand  uniformly  as  it  extends  into  the  tooth. 

The  manner  of  opening  up  and  preparing  the 
cavity  for  filling,  will  depend  somewhat  on  the  form 
given  to  it  by  the  decay.  If  it  is  larger  at  the  orifice 
than  within,  there  will  be  little  or  no  cutting  of  the 
cavity  about  the  orifice  necessary ;  and  its  prepara- 
tion will  consist  in  an  entire  removal  of  the  decay, 
and  such  a  shaping  of  the  interior  as  will  insure  a 
perfect  retention  of  the  filling.  This  may  be  effected 
either  by  enlarging  the  cavity  within,  till  its  walls 
are  parallel  with  each  other,  or,  if  these  are  left  con- 
verging, by  forming  pits  or  grooves  upon  them  at 
proper  points.  Converging  walls  present  one  or  two 
advantages,  which  will  be  hereafter  considered. 
Usually,  where  the  decay  has  formed  a  cavity  of 
nearly  uniform  diameter  from  the  orifice  to  the  bot- 
tom, all  the  preparation  for  filling  that  is  requisite,  is 
a  thorough  removal  of  the  decay.  In  cases  in  which 
the  decay  burrows  under  the  enamel,  the  projecting 
portions  are  to  be  cut  down,  either  with  a  bur  drill, 
or,  what  is  generally  better,  with  a  heavy  cutting 
instrument.  In  most  instances,  it  is  best  to  cut  away 
the  enamel  as  far  as  the  decay  has  extended  beneath 
it,  since  it  is  difficult  to  make  a  perfect  filling  under 
a  projecting  portion.  In  some  cases,  however,  where 
the  enamel  is  thick  and  firm,  it  may  be  admissible  to 


170  CLASSIFICATION    OF    DECAYED    CAVITIES. 

leave  a  slight  projection,  so  as  to  form,  as  it  were,  a 
shallow  groove. 

The  walls  of  these  cavities  will  be  of  various  in- 
clinations. If  they  converge,  pits  or  grooves  may  be 
required  upon  them  for  retaining  points,  especially  if 
the  enamel  be  cut  away  at  the  orifice  to  the  solid 
dentine.  If,  however,  the  walls,  or  two  opposite 
walls,  are  parallel,  or  but  slightly  divergent,  these 
special  retaining  points  will  not  be  necessary.  Small 
cavities  of  this  class  may  be  opened  up  and  formed 
principally  with  the  bur  drill ;  but  in  large  cavities, 
this  instrument  is  not  available.  Thus  the  orifices  of 
the  small  cavities  would  be  round,  while  those  of  the 
large  would  be  of  various  forms,  determined  by  the 
direction  of  the  decay;  as,  round,  square,  triangular, 
elliptical,  parallelogramic.  Cavities  should  not  be 
formed  much  larger  within  than  at  their  orifices,  un- 
less the  filling  can  be  consolidated  so  perfectly  that  it 
will  not  yield  in  the  least  under  the  greatest  pressure 
of  mastication ;  for,  if  there  is  any  yielding  in  such 
cases,  under  direct  pressure,  the  filling  being  forced 
into  a  larger  part  of  the  cavity,  withdraws  from  the 
walls,  leaving  an  interval  coextensive  with  the  de- 
pression it  has  undergone ;  and  thus  fluids  would  be 
admitted  in  between  the  walls  and  the  filling,  and 
the  purpose  for  which  this  was  inserted  would  be 
entirely  defeated. 

Many  operators  ream  the  orifices  of  all  the  small 


FILLING    BY    CLASSES   AND    MODIFICATIONS.  171 

and  medium-sized  cavities  of  this  class,  in  order 
thereby  to  make  a  better  finish  to  the  border  of  the 
filling.  All  acute  angles  in  these  cavities,  especially 
if  they  extend  to  the  orifice,  should  be  obliterated, 
since  it  is  impossible  to  fill  them  perfectly.  This 
obliteration  can  be  effected  with  a  miniature  chisel, 
or  with  the  appropriate  excavator. 

After  the  formation  of  the  cavity,  the  next  par- 
ticular is  so  to  arrange  as  entirely  to  exclude  moist- 
ure, whether  from  the  saliva  or  from  the  breath. 
Ordinarily,  in  operations  on  the  superior  teeth,  the 
following  arrangement  will  be  sufficient  for  the  pur- 
pose :  "Wipe  dry  the  mucous  membrane  about  the 
mouth  of  the  duct-of-Wharton ;  lay  directly  upon 
this  a  piece  of  heavy  blotting  paper,  or  a  roll  of  bibu- 
lous paper;  then  take  a  napkin  folded  cornerwise, 
place  the  end  of  it  upon  the  paper,  between  the 
cheek  and  the  gum,  passing  it  back  of  the  tooth  to  be 
operated  upon,  along  the  palatal  surfaces  of  the  teeth 
and  the  gums  to  the  anterior  part  of  the  mouth,  and 
letting  a  fold  of  it  extend  down  from  this,  so  as  to 
protect  the  tooth  from  the  breath,  and  catch  any  frag- 
ment of  gold  that  may  drop  from  the  instrument. 
The  napkin  and  paper  thus  arranged,  are  to  be  kept 
in  their  place  by  the  fingers  of  the  left  hand  of  the 
operator;  and,  if  the  mouth  of  the  duct  is  kept  closed 
by  the  paper,  a  complete  exclusion  of  moisture  is  se- 
cured.    In  some  cases,  pressure  of  the  fingers  on  the 


172 


CLASSIFICATION    OF    DECAYED    CAVITIES. 


napkin  over  the  duct  is  necessary;  in  others,  the 
paper  adheres  to  the  mucous  membrane,  and  effectu- 
ally prevents  the  egress  of  saliva.  The  cavity  should 
now  be  dried  by  the  method  heretofore  described,  and 
it  is  ready  for  the  filling. 

In  operations  on  inferior  teeth,  more  care  is  requisite 
to  exempt  them  from  moisture.  Bibulous  paper 
should  be  packed  in  on  the  mouths  of  the  sublingual 
and  submaxillary  ducts,  and  a  roll  of  paper  placed 
between  the  cheeks  and  the  teeth.  A  larger  roll  of 
napkin,  too,  than  that  used  for  the  upper  teeth, 
should  be  disposed  in  the  same  manner  as  above  sug- 


Fig.  31. 


gested,    and    held    in    place    by    the   patient  with  a 
speculum   (Fig.  31),  or  by  the  operator  and  patient 


FILLING    BY    CLASSES    AND   MODIFICATIONS. 


173 


with  their  fingers.  Various  appliances  have  been 
used  for  holding  away  the  cheek,  keeping  down  the 
tongue,  and  retaining  the  jaws  apart ;  but  the  method 
above  given,  with  the  addition  of  a  cork  to  hold  apart 
the  jaws,  will  be  found  efficient  in  a  majority  of  cases, 
and  more  convenient  than  complicated  appliances. 
An  excellent  instrument,  however,  for  this  purpose, 

Fig.  32. 


has  been  recently  invented  by  Dr.  C.  C.  Thomas     Fig. 
32  will  give  a  correct  idea  of  this  instrument. 

Filling  with  Foil. — If  nonadhesive  gold  is  employed, 
it  should  be  formed  into  blocks,  by  cutting  from  four 
to  eight  thicknesses  into  strips  one  fourth  wider  than 
the  cavity  is  deep,  and  rolling  them  on  a  broach  suit- 
able for  the  purpose,  into  cylindrical  blocks  corres- 
ponding in  size  with  the  cavity  to  be  filled,  and 
varying  not  only  in  size,  but  in  form  and  density. 
The  blocks  first  to  be  introduced  should  be  largest, 
followed  by  those  diminishing    in    size,  till  the  last 


174  CLASSIFICATION    OF    DECAYED    CAVITIES. 

portions  should  be  very  small;  dense,  conical  rolls. 
Where  there  is  an  inward  or  an  outward  inclination 
of  the  walls  of  the  cavity,  the  first  blocks  should  be 
cone-shaped.  For  introducing  the  blocks,  the  plug- 
ging pliers  will  be  required.  The  first  block  is  taken 
up  with  this  instrument,  and  placed  against  the  pos- 
terior wall  of  the  cavity  with  one  end  on  the  bottom 
and  the  other  protruding  from  the  orifice,  and  there 
compressed  firmly  to  its  place  with  the  appropriate 
condensing  instrument;  and,  unless  there  is  some 
special  retaining  point,  it  may  be  necessary  to  hold  it 
in  its  position  with  a  second  instrument,  till  the  next 
portion  is  added.  As  the  successive  blocks  are  intro- 
duced, each  is  to  be  thoroughly  consolidated,  so  as  to 
be  wholly  immovable.  The  filling  is  to  proceed  from 
the  posterior  walls  to  the  center.  After  the  cavity- 
has  thus  been  filled  up  to  the  center,  commence  in 
the  same  manner  at  the  anterior  wall,  consolidating 
from  there  back  toward  the  center  again,  and  con- 
densing the  last  blocks  by  forcing  in  at  their  side  a 
small  sharp-pointed  instrument :  the  final  portion  in- 
troduced will  be  the  small,  dense,  conical  roll  already 
mentioned.  The  gold  being  all  introduced,  a  fine 
square-pointed  instrument  condenses  the  projecting 
portion  of  the  filling  till  it  is  perfectly  solid,  when  it 
is  rubbed  down  with  a  rough  instrument,  and  then 
finished  with  a  file,  stone,  and  burnisher,  in  the 
manner  already  described.     The  particular  shape  of 


FILLING   BY    CLASSES    AND    MODIFICATIONS.  175 

the  surface  of  the  filling  will  be  suggested  by  the 
form  of  the  antagonizing  tooth.  If  there  is  nothing 
to  prevent,  the  surface  should  be  slightly  convex  ;  but 
if  there  are  cusps  striking  upon  the  center  of  the 
crown,  concave. 

For  dressing  down  the  filling  when  a  concave  sur- 
face is  required,  the  instrument  represented  in  Fig. 
33  is  very  efficient.     It  consists  of  a  spherical  file, 


Fi<r.  33. 


finely  cut,  and  on  a  proper  shaft  or  handle ;  and  may 
be  used  in  the  manner  of  the  ordinary  bur  drill.  A 
variety  of  sizes,  at  least  four,  should  be  at  hand,  in 
order  to  operate  properly  upon  fillings  of  various  sizes. 
Adhesive  Foil. — For  the  purpose  of  filling  these 
cavities  with  adhesive  foil,  definite  retaining  points 
must  be  formed  in  them.  The  gold,  prepared  in  the 
manner  already  described,  is  taken  up  with  a  serrate- 
pointed  plugger,  introduced  into  the  retaining  point 
or  points,  and  there  fixed ;  it  is  then  built  across 
from  one  to  the  other,  and  over  the  floor  of  the 
cavity,  till  this  is  completely  covered,  and  then  up 
from  the  bottom  to  the  orifice.  When  a  portion  of 
gold  is  taken  on  the  point  of  the  instrument,  the  pre- 
cise spot  at  which  to  deposit  it  should  be  selected, 


176  CLASSIFICATION    OF    DECAYED    CAVITIES. 

and  there  it  should  be  placed,  and,  by  the  first  press- 
ure of  the  instrument,  fixed  immovably ;  a  few  sub- 
sequent strokes  of  the  instrument  close  about  the  first 
point  of  attachment,  will  be  required.  These  strokes 
should  be  close,  because  if  the  instrument  is  lifted  up 
and  pressed  upon  the  piece  at  a  distance  from  the 
first  point  of  contact,  the  attachment  is  liable  thus  to 
be  broken  up.  In  constructing  the  filling,  we  con- 
sider it  preferable  to  keep  it  built  up  a  little  higher 
all  around  next  the  walls  than  at  the  center,  for  the 
reason  that  a  more  complete  adaptation  of  the  gold 
can  thus  be  made,  than  by  any  other  plan.  Some, 
however,  advocate  the  opposite  practice ;  that  is,  of 
keeping  the  filling  higher  in  the  center  than  at  the 
walls,  and  thus  forming  an  angular  space  into  which 
to  crowd  the  gold;  because  they  think  that  the  gold 
is  thus  kept  in  more  thorough  contact  with  the  walls 
of  the  cavity ;  and  they  object  to  the  other  practice, 
that,  to  add  and  consolidate  the  gold  to  the  center, 
while  the  edges  are  left  higher,  tends  to  draw  them 
from  the  walls.  This  objection,  however,  has  no 
force,  if  the  gold  is  thoroughly  consolidated  as  it  is 
introduced. 

The  cavity  is  thus  filled  up,  consolidated,  and  fin- 
ished in  the  usual  manner.  Tn  adding  the  last  por- 
tions of  gold,  great  care  should  be  taken  to  make  a 
perfect  border  to  the  filling.  Crystal  gold  may  be 
very  advantageously  used  as  a  foundation  for  aclhe- 


FILLING   BY   CLASSES    AND    MODIFICATIONS.  177 

sive-foil  fillings,  as  it  will  retain  its  position  perfectly 
in  a  cavity,  where  adhesive  foil  would  not. 

Crystal  Gold. — The  method  of  filling  this  class  of 
cavities  with  crystal  gold  is  very  simple.  The  ma- 
terial should  be  annealed  just  before  its  use,  and  then 
cut  or  broken  into  blocks  corresponding  with  the  size 
of  the  cavity  to  be  filled :  many  small  pieces  will  be 
required  to  fill  up  interstices  or  angles,  and  they 
may  be  used  as  large  as  will  freely  enter  the  cavity. 
The  filling  may  be  commenced  at  the  bottom  of  the 
cavity,  and  built  up  from  that  to  the  orifice,  the  same 
plan  being  followed  in  adapting  it  to  the  walls  as 
with  adhesive  foil,  the  pieces  being  passed  into  the 
cavity  with  either  the  plugging  pliers,  or  a  serrate- 
pointed  condensing  instrument.  Each  piece  should 
be  thoroughly  consolidated  before  an  other  is  added. 
For  condensing  the  filling  next  to  the  walls,  a  small 
double-pointed  or  wedge-shaped  instrument  is  valua- 
ble. In  all  cases  where  there  is  a  divergence  of  the 
anterior  wall,  much  care  is  required  in  order  to  make 
a  perfect  filling ;  and  too  much  care  can  not  be  exer- 
cised in  perfecting  the  filling  round  the  border  of  the 
cavity.  In  condensing  adhesive  foil  or  crystal  gold, 
the  force  may  be  applied  almost  exclusively  in  a  line 
with  the  axis  of  the  tooth;  and  this  is  always  prefer- 
able to  lateral  pressure. 

1st  Mod. — Extension  of  decay  along  one  or  more 
crown  fissures.     In  a  case  of  this  kind,  the  central 


178  CLASSIFICATION    OF    DECAYED    CAVITIES. 

cavity  is  first  to  be  opened  and  excavated,  according 
to  the  principles  already  announced.  Decay  in  the 
fissures  is  in  some  cases  an  extension  of  this  central 
decay,  and  at  the  point  of  its  termination  there  will 
be  found  an  acute  angle ;  but  in  others,  it  will  be  the 
effect  of  an  equal  attack  all  along  the  fissure,  or  of 
an  extension  from  some  other  point  than  the  central 
cavity.  This  modification  of  decay  may  terminate 
not  only  in  an  acute  angle,  but  also  in  an  expansion. 

These  decayed  fissures  should  be  opened  up  by 
cutting  away  any  projecting  portion  of  enamel,  and 
the  cavities  formed  with  a  small  chisel-shaped  instru- 
ment, beginning  at  the  juncture  of  the  fissure  with 
the  main  cavity,  and  cutting  down  to  the  bottom  of 
the  decay  in  the  manner  of  a  mortise,  thus  oblitera- 
ting the  entire  fissure  and  the  acute  angle  at  its  ter- 
mination— the  latter  an  important  consideration.  In 
case  there  is  a  very  considerable  expansion  of  decay 
at  the  termination  of  the  fissure,  the  bur  drill  may  be 
introduced  into  it,  and  the  rest  of  the  fissure  cut  out, 
as  the  character  of  the  decay  may  indicate. 

If  blocks  are  used  to  fill  these  cavities,  they  should 
be  set  in  and  compressed  against  the  end  of  the 
fissure,  protruding  from  it  sufficiently  to  admit  of  a 
proper  finish ;  and  block  after  block  then  added,  till 
the  fissure  is  filled  up  to  the  main  cavity.  Where 
there  are  two  or  three  of  these  decayed  fissures  in 
one  tooth,  it  may  be  quite  as  much  as  can  be  done  at 


FILLING   BY   CLASSES   AND   MODIFICATIONS.  179 

one  sitting,  to  fill  them,  the  main  cavity  being  left 
for  an  other  time.  In  such  cases,  the  filling  intro- 
duced at  the  first  sitting,  should  then  be  consolidated 
and  burnished,  so  that  it  may  not  absorb  moisture 
till  the  main  cavity  is  filled,  as  already  described. 
Much  care  should  be  exercised  to  prevent  the  gold 
from  overlapping  the  enamel  at  the  sides  of  these 
fissures.  In  filling  this  modification  with  crystal 
gold  or  annealed  foil,  it  is  better  to  begin  at  the 
bottom  of  the  cavity  and  build  up  to  the  orifice,  first 
completing  the  fissure,  as  we  have  already  described, 
and  afterward  the  main  cavity. 

2.d  Mod. — Two  cavities  on  the  same  crown  in  close 
proximity.  The  thickness  of  the  portion  of  tooth 
intervening  between  two  cavities  on  the  grinding  sur- 
face of  the  same  crown,  is  determined  by  the  extent 
of  the  decay  ;  and  the  form  of  it,  by  the  form  of  the 
cavities;  and  these  two  qualities  will  suggest  the 
method  of  operation.  If  this  intervening  portion  is 
thin  throughout,  and  devoid  of  vitalitj^,  it  should  be 
cut  away,  and  the  two  cavities  formed  into  one;  but 
if  it  is  thick  within,  though  it  may  be  thin  at  the 
surface,  the  cavities  should  be  filled  separately.  In 
some  cases  it  is  proper  to  leave  a  part  of  it  standing, 
as  a  sort  of  ridge  between  the  cavities,  though  not  as 
a  definite  partition ;  in  which  cases,  the  filling  would 
be  begun  as  in  two  cavities,  and  finished  as  in  one. 
In  no  case,  however,  when  the  tooth  is  living,  should 


180  CLASSIFICATION    OF   DECAYED    CAVITIES. 

this  intervening  portion  remain,  if  its  vitality  is  gone. 
The  details  of  the  process  of  filling  crown  cavities, 
have  already  been  indicated. 

Second  Class. — Buccal  and  palatal  cavities  of  the 
molars  and  bicuspids,  and  labial  and  palatal  cavities 
of  the  canines  and  incisors.  In  the  molars,  this  class 
of  decay  begins  either  at  the  margin  of  the  gum,  in 
the  form  of  a  transverse  groove,  or  along  the  vertical 
depression  on  the  buccal  surface  of  the  tooth,  or  at 
its  termination.  These  groovelike  decays,  extending 
along  the  side  of  the  tooth  at  or  near  the  margin  of 
the  gum,  are  ordinarily  not  very  deep ;  but  they 
burrow  considerably  under  the  enamel,  particularly 
at  the  side  next  the  grinding  surface.  In  preparing 
these  cavities,  the  projecting  portion  of  the  enamel 
must  be  mostly  cut  away,  leaving  them  but  slightly 
larger  within  than  at  the  orifice.  These  grooves,  at 
their  ends,  are  shallow ;  but  in  their  preparation  for 
filling,  they  should  be  cut  as  deep  at  the  ends  as 
elsewhere,  and,  when  the  main  part  of  the  cavity  is 
comparatively  shallow,  deeper. 

The  method  of  introducing  gold  in  the  form  of 
blocks  into  these  cavities,  is,  to  set  in  the  first  block 
at  the  posterior  part  of  the  cavity,  and  consolidate 
it,  and  so  one  block  after  an  other,  till  the  cavity  is 
nearly  full;  and"  then  proceed  in  like  manner  with 
the  anterior  end,  back  toward  the  middle,  the  blocks, 
of  course,  being  permitted  to  protrude  sufficiently  for 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  181 

the  purposes  of  a  finish.  For  filling  with  crystal  gold 
or  adhesive  foil,  the  method  is,  to  form  pits  at  the 
end  of  the  groove,  into  which  the  gold  is  consolidated, 
and  built  across  from  one  to  the  other,  and  then  up 
from  the  bottom  to  the  orifice,  when  it  is  finished  as 
usual.  Care  is  requisite  to  prevent  the  gold  from 
overlapping  the  tooth. 

Those  cavities  of  this  class,  which  are  formed  in 
the  depressions  of  the  buccal  portions  of  the  teeth, 
are  more  easily  filled.  Often  a  simple  round  cavity 
is  formed,  which  may  be  entirely  prepared  with  a 
bur  drill.  The  method  of  filling  these  cavities  will 
be  readily  inferred  from  the  remarks  before  made. 
If,  however,  the  decay  extends  along  the  depressions, 
making  a  groovelike  cavity,  this  should  be  filled  by 
commencing  the  introduction  of  the  gold  at  that  side 
of  the  cavity  next  the  gum. 

1st  Mod. — Decay  at  or  near  the  neck  of  the  tooth, 
and  partially  or  wholly  overlapped  by  the  free  border 
of  the  gum.  In  this  modification,  the  gum  is  a  great 
obstacle  to  the  various  steps  in  the  process  of  filling  : 
it  is  liable  to  be  wounded  and  to  bleed  at  every 
touch ;  it  exudes  mucus  constantly ;  and  it  conducts 
saliva  to  the  parts  with  great  facility.  To  obviate 
these  difficulties,  the  gum  must  be  removed  somewhat 
from  the  cavity,  before  the  filling  is  practicable. 
This  removal  of  the  free  margin  of  the  gum,  may  be 
made  either  by  cutting  away,  or  by  pressing  away 


182  CLASSIFICATION    OF    DECAYED    CAVITIES. 

with  pledgets  of  cotton  or  other  appropriate  substance 
placed  in  the  cavity  and  overfilling  it,  so  as  to  induce 
a  partial  absorption  of  the  gum  pressed  upon,  in  a  few 
days.  The  former  method,  however,  accomplishes 
the  object  at  once :  some  good  hemostatic,  or  cautery, 
as  nitrate  of  silver  or  chlorid  of  zinc,  is  all  that  is 
then  necessary  to  render  the  filling  immediately 
practicable.  By  means  of  the  cautery,  the  exudation 
is  checked — which,  where  there  is  much  mucus  eli- 
minated, is  an  important  item — and  also  such  a  sur- 
face is  given  to  the  part,  that  it  will  not  so  readily 
conduct  the  saliva.  It  is,  perhaps,  preferable  in  many 
cases  to  cut  away  this  free  margin,  so  that  it  shall 
not  be  in  contact  with  the  filling  after  the  operation 
is  completed. 

After  this  preparation,  the  cavity  is  formed  and 
filled  as  usual.  The  napkins  and  paper  are  to  be 
placed  in  the  precise  position,  and  carefully  retained 
there.  Two  or  three  thicknesses  of  paper  should  be 
laid  on  the  gum  up  to  the  margin  of  the  cavity,  and 
kept  there  during  the  process  of  filling,  so  as  to  ex- 
clude all  moisture.  In  filling  cavities  of  the  buccal 
portions  of  the  denies  sapientice,  peculiar  difficulties  are 
met  with  :  the  decay  is  frequently  found  two  thirds 
covered  by  the  gum ;  the  muscles  of  the  cheek,  thick 
and  rigid,  lie  close  against  the  side  of  the  tooth;  and, 
in  most  cases  of  this  kind,  the  view,  at  best,  is  but 
partial.     In  operating  upon  these  cavities,  an  instru- 


FILLING   BY   CLASSES   AND    MODIFICATIONS.  183 

ment  for  holding  out  the  cheeks  is  required.     (See 
Fig.  29.) 

Third  Class. — Anterior  proximal  cavities  of  the 
molars  and  bicuspids.  This  class  of  cavities  in  teeth 
with  short,  broad  crowns,  takes  place  at  their  necks; 
but  in  those  with  long  crowns,  and  with  a  diameter 
less  at  the  neck  than  at  the  masticating  surface,  it 
begins  at  some  distance  from  the  neck,  toward  the 
crown  surface,  or  at  the  first  point  of  contact  of  the 
crowns;  in  which  case  the  teeth  ordinarily  require 
separation.  The  method  and  extent  of  this  will  be 
determined  by  circumstances.  If  all  the  neighboring 
teeth  stand  in  contact,  it  can  not  be  accomplished  by 
pressure ;  but,  if  a  tooth  has  been  extracted  in  the 
vicinity,  or  there  are  natural  spaces  between  the 
others,  it  can  be,  either  in  whole  or  in  part.  When, 
however,  the  teeth  stand  close  together,  they  must  in 
such  case  be  separated  wholly  with  the  chisel  and 
file.  If  but  one  is  decayed,  the  cutting  should  be 
exclusively  from  that.  If  two  are  alike  affected  on 
their  proximal  surfaces,  it  should  be  mostly  from  the 
posterior  surface  of  the  anterior  tooth,  and  should 
leave  a  space  in  the  form  of  a  V.  There  should  be 
no  shoulder  left  at  the  neck  of  the  tooth,  but  the  cut 
surface  should  be  plain  from  the  crown  to  its  termina- 
tion at  or  near  the  neck.  The  interval  should  be  large 
enough  to  enable  the  operator  to  manipulate  with  facil- 
ity, and  to  see  as  directly  as  possible  into  the  cavity. 


184  CLASSIFICATION    OF   DECAYED    CAVITIES.  . 

Cavities  of  this  class  are  various  in  form ;  and  they 
require  much  skill  in  their  excavation  and  formation. 
Great  care  is  to  be  exercised  not  to  leave  any  portion 
of  decay  in  them.  By  a  fatal  oversight,  decayed 
dentine  is  often  permitted  to  remain  on  that  side 
next  to  the  neck  of  the  tooth ;  and  we  have  seen 
fillings  that  in  other  respects  were  good,  very  defi- 
cient here ;  so  deficient,  indeed,  that  a  sharp  instru- 
ment would  readily  penetrate  the  softened  dentine 
above  them,  or  even  pass  between  the  filling  and  the 
wall  of  the  cavity.  The  removal  of  the  decay  from 
the  cervical  walls  of  all  proximal  cavities  is  an  im- 
portant particular,  neglect  of  which  occasions  thous- 
ands of  failures.  This  class  of  cavities  at  this  point 
should  be  most  thoroughly  filled ;  for  it  is  a  point 
more  vulnerable  than  any  other,  on  account  of  the 
facility  with  which  foreign  substances  are  here  lodged 
and  retained. 

In  the  formation  of  these  cavities,  the  cervical  wall 
should  be  made  to  incline  slightly  inward,  and  the 
lateral  walls,  if  the  tooth  will  bear  the  loss,  made  at 
least  parallel  with  each  other ;  but  if  that  would  im- 
pair its  strength,  grooves  or  pits  may  be  made  upon 
them  for  this  purpose  at  proper  points.  When  these 
cavities  are  large,  the  dentine  is  usually  all  decayed 
in  that  part  of  the  cavity  next  to  the  masticating 
surface  of  the  tooth;  in  which  case,  the  enamel  there 
would  constitute  the  outside  of  the  cavity's   upper 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  185 

wall ;  and  in  such  case  no  cutting  in   that  part  is 
admissible. 

Great  pains  must  be  taken  to  arrange  and  dispose 
the  napkins  and  bibulous  paper  so  as  to  protect  the 
cavity  from  moisture  during  the  process  of  filling.  A 
roll  of  paper  should  be  placed  on  each  side  of  the 
tooth,  and  on  the  paper  the  napkin,  properly  folded, 
should  be  laid,  and  kept  in  place  by  the  operator 
with  the  left  hand,  or  by  the  patient  with  the  specu- 
lum. The  gum  between  the  teeth  is  liable  to  secrete 
mucus  enough  to  moisten  the  work,  or  to  be  touched 
by  the  instrument  so  as  to  bleed ;  and  to  obviate 
these  difficulties,  a  small  piece  of  soft  wood  should  be 
wedged  down  between  the  teeth  below  the  cavity,  so 
as  to  press  the  gum  out  of  the  way,  and  thus  provide 
against  both  contingencies. 

In  addition  to  these  preparations,  it  will,  in  many 
cases,  be  necessary  to  place  a  cork  between  the  jaws, 
in  order  to  keep  them  apart  during  the  operation. 
By  this  arrangement  the  mouth  being  propped  open, 
the  soft  parts  are  sustained  more  in  repose,  and  so 
less  saliva  is  eliminated  from  them  to  interfere  with 
the  work. 

With  this  preliminary,  the  cavity  is  ready  for  the 
filling,  which  is  introduced,  if  in  blocks,  as  before  de- 
tailed, beginning  with  the  cervical  wall.  The  caution 
may  here  again  be  urged,  not  to  let  the  gold  overlap 
the  tooth,  particularly  at  the  cervical  wall.     In  filling 


186  CLASSIFICATION    OF   DECAYED   CAVITIES. 

with  crystal  gold  or  adhesive  foil,  special  retaining 
points  will  be  required  in  this  wall,  two  being  gen- 
erally sufficient,  one  toward  the  outer,  and  the  other 
toward  the  inner  lateral  wall,  on  which  walls,  too, 
grooves  may  be  made,  if  the  walls  are  thick  enough 
to  admit  of  it.  If,  however,  these  walls  are  not 
parallel,  and  will  not  admit  of  grooves,  the  crown 
and  the  cervical  wall  should  be  so  shaped  as  to  retain 
the  filling.  But  in  some  cases  the  attachment  of  the 
filling  is  made  entirely  at  the  cervical  wall ;  and  best 
by  means  of  three  pits,  bored  with  the  square-pointed 
drill,  at  different  angles,  and  in  such  directions  as  not 
to  interfere  with  the  pulp.  This  kind  of  attachment 
will  serve  only  for  adhesive  gold,  which  is  to  be  very 
thoroughly  consolidated  into  the  pits,  and  built  very 
firmly  across  from  one  to  the  other,  making  little 
projections,  which  are  so  many  anchors  for  fastening 
the  filling;. 

2d  Mod. — Decay  involving  a  portion  of  the  masti- 
cating surface.  There  are  two  methods  of  filling  this 
modification.  One  is,  to  cut  down  the  tooth  or  the 
projecting  angles,  and  make  a  plain,  oblique  border  to 
the  cavity,  and  then  fill  up  flush  with  this  border. 
The  filling  will  thus  exhibit  a  single,  uniform  surface, 
at  a  considerable  angle  with  the  axis  of  the  tooth. 
When  a  portion  of  the  crown  breaks  down  in  conse- 
quence of  proximal  decay,  it  is  toward  the  center  of 
the  tooth ;  usually  the  inner  and  outer  corners  re- 


FILLING    BY    CLASSES   AND    MODIFICATIONS.  187 

main.  If  these  projections  are  feeble  and  liable  to 
be  broken  away,  they  should  be  cut  down,  and  the 
cavity  filled  as  before  described.  If,  however,  they 
are  firm,  they  may  remain,  and  the  cavity,  properly 
formed,  may  be  filled  so  as  almost  to  restore  the 
tooth's  original  form.  This  method  is  seldom  appli- 
cable to  the  bicuspids,  but  is  often  available  in  filling 
the  molars.  Nonadhesive  foil  is  not  adaptable  to  this 
kind  of  filling,  as  it  can  not  be  built  in  so  as  to  with- 
stand the  pressure  of  mastication.  A  free  space  is  to 
be  left  between  the  filling  and  the  adjoining  tooth. 

Fourth  Class. — Proximal  cavities  of  the  incisors 
and  canines.  If  the  teeth  are  not  in  a  corroded  con- 
dition, and  the  file  is  not  required  by  the  strength  of 
the  decay,  separation  may  be  made  by  pressure,  if 
there  are  no  forbidding  circumstances ;  but  if  the 
cavity  is  large,  and  the  walls  are  thin,  separate  with 
a  thin  chisel  and  file.  Much  has  been  said  as  to  the 
manner  of  separating  these  teeth,  some  recommend- 
ing that  the  separation  be  larger  at  the  palatine  part 
than  at  the  labial ;  others,  that  it  be  larger  at  the 
points  than  at  the  necks  of  the  teeth ;  some,  that  a 
shoulder  be  left  at  the  necks;  and  others,  that  there 
be  no  shoulder  at  all.  In  making  these  separations, 
however,  the  operator  must  be  governed  somewhat 
by  circumstances,  no  general  rule  being  applicable  to 
all  cases.  The  form  of  the  teeth  and  the  extent  of 
the  decay  will  modify  the  form  of  the  space  between 


188  CLASSIFICATION    OF    DECAYED   CAVITIES. 

them.  If  the  inner  wall  is  thin  or  broken  away,  it 
should  be  cut  off  more  than  the  outer;  in  which  case, 
the  palatine  portion  of  the  separation  will  be  the 
largest — as,  indeed,  some  prefer  to  make  it  in  all 
cases,  performing  then  the  remainder  of  the  operation 
from  the  inside.  But  this  is  a  disadvantageous 
method  ;  for  the  cavity  is  more  difficult  of  access  from 
within  than  from  without,  and  the  view  is  less  per- 
fect, unless  aided  by  a  mirror,  the  use  of  which  is 
always  attended  with  inconvenience :  it  is  preferable 
to  make  the  separation  so  that  the  principal  part  of 
the  work  can  be  done  from  the  front. 

In  some  cases,  separation  will  be  larger  at  the 
points  of  the  teeth  than  elsewhere ;  as,  where  there 
has  been  a  partial  fracture  at  the  points.  In  cutting 
away,  to  make  the  separation,  no  shoulder  should  be 
left  at  the  neck  of  the  tooth ;  any  projection  of  that 
kind  is  always  objectionable  :  it  is  not  protected  by 
the  filling;  foreign  substances  lodge  upon  and  adhere 
to  it,  and,  becoming  vitiated,  render  it  very  liable  to 
decay.  The  cutting  should  always  extend  entirely 
beyond  the  decay,  but  only  far  enough  to  make  a 
perfectly  plain  border  to  all  the  cavity,  and  should 
terminate  without  any  projection.  It  is  highly  im- 
portant, in  separating  the  anterior  teeth,  to  make  as 
little  alteration  as  possible  in  their  form.  But  the 
preservation  of  the  tooth  should  not  be  jeopardized 
for   the    sake    of    maintaining    the   integrity    of   its 


FILLING   BY   CLASSES   AND    MODIFICATIONS.  189 

natural  form.  The  first  consideration  should  be,  to 
obtain  a  space  sufficient  for  the  purposes  of  a  perfect 
operation ;  the  second,  to  have  the  walls  and  border 
of  the  cavity  in  such  a  condition  that  an  efficient 
filling  can  be  made ;  and  the  form  and  beauty  of  the 
tooth  may  be  reckoned  the  third  consideration. 

The  excavation  of  these  cavities  requires  very  deli- 
cate and  skillful  manipulation,  since  they  are  very 
readily  injured  hy  cutting  too  much  or  at  a  wrong 
point.  All  decayed  and  discolored  portions  must  be 
entirely  removed,  as  well  for  the  appearance  of  the 
tooth,  as  for  the  permanency  of  the  operation  ;  after 
which,  the  cavity  is  to  be  formed  with  great  care. 
At  the  point  of  the  tooth  the  dentine  often  has  all 
been  displaced  by  decay,  leaving  only  the  two  plates 
of  enamel  joined  at  the  edge,  and  thus  forming  an 
acute  angle,  the  obliteration  of  which  is  always 
attended  with  risk,  unless  great  care  is  exercised ; 
and  it  is  very  difficult  perfectly  to  fill  a  very  acute 
angle.  The  inclination  of  the  inner  and  the  outer 
wall  of  the  cavity  will  depend  on  its  size :  when  this 
is  small  or  medium,  they  may  be  parallel,  or,  if 
necessary,  slightly  divergent;  but  when  large,  it  is 
better  not  to  cut  much  of  the  healthy  dentine  from 
them,  lest  they  be  thus  weakened.  Small  grooves, 
however,  are  admissible  on  these  walls,  near  the 
bottom  of  the  cavity,  when  they  incline  to  the  center, 
and  are  generally,  in  such   case,  to  be  preferred  to 


190  CLASSIFICATION    OF    DECAYED    CAVITIES. 

pits.  More  cutting  is  allowable  on  the  cervical  wall 
than  elsewhere,  as  there  is  no  danger  here  of  weak- 
ening the  tooth  by  excavation.  In  filling  with 
adhesive  gold,  we  may,  if  necessary,  rely  exclusively 
on  this  part  of  the  cavity  for  the  retention  of  the 
plug ;  and  the  best  method  of  preparing  it  is,  to  make 
two  or  three  little  pits  in  it  at  different  angles,  with 
a  fine,  square-pointed  drill.  An  other  method  is,  to 
form  two  pits,  and  make  a  groove  from  one  to  the 
other.  Some  operators  prepare  these  cavities  by 
making  pits  in  each  of  the  walls.  This,  however,  is 
unnecessary,  if  the  cervical  wall  is  properly  prepared. 

The  cavity  being  prepared,  the  rolls  of  bibulous 
paper  or  napkin  should  be  placed  on  the  gum  inside, 
and  between  the  gum  and  the  lip ;  and  if  the  former 
has  been  wounded  between  the  teeth,  or  if  it  elimi- 
nates mucus,  a  small  piece  of  soft  wood  or  of  rubber 
should  be  crowded  down  upon  it  below  the  cavity. 
The  gold,  prepared  as  already  described,  should  then 
be  introduced  with  a  small  plugger  serrated  with  four 
points,  and  somewhat  flattened  about  a  line  above  the 
point,  so  as  to  be  freely  used  when  introduced  into 
the  cavity.  The  gold  is  taken  up  on  the  point  of 
this  plugger,  and  condensed  in  the  pits  of  the  cervical 
wall;  which  being  completely  filled,  and  the  gold 
extending  from  one  to  the  other,  the  foundation  is 
ready  for  the  remainder  of  the  filling. 

Great  care  is  requisite,  in  packing  the  gold  into 


FILLING   BY   CLASSES  AND    MODIFICATIONS.  191 

these  cavities,  perfectly  to  adapt  and  adjust  it  to  all 
their  points,  so  as  to  insure  its  thorough  contact  with 
every  part  of  their  interior.  If  the  form  of  the  tooth 
has  been  measurably  retained,  and  the  border  of  the 
cavity  is  even,  the  surface  of  the  plug  should,  when 
finished,  be  slightly  convex ;  and,  in  introducing  the 
filling,  reference  should  be  had  to  this  particular. 
The  cavity  may  be  filled  up  two  thirds  of  the  way  to 
the  wall  next  the  point  of  the  tooth,  and  then  its  re- 
maining portion  filled  from  the  point  back  to  the 
preceding  filling;  or,  what  is  probably  better,  begun 
at  the  bottom  and  filled  to  the  surface,  and  then 
finished  in  the  usual  manner. 

For  filling  these  cavities  with  nonadhesive  foil,  the 
special  retaining  points  already  described  are  not  re- 
quired ;  but  the  cervical  wall  of  the  cavity  is  slightly 
cut  under,  and  the  lateral  walls  so  shaped  as  to 
secure  the  filling  in  place.  These  cavities  are  in 
some  cases  very  difficult  to  fill  with  nonadhesive  foil, 
whether  in  the  form  of  blocks  or  otherwise,  especially 
where  they  are  large,  with  the  walls  inclined  to  the 
center,  and  the  tooth  bone  friable.  To  force  a  wedge- 
shaped  instrument  into  these  fillings,  for  the  purpose 
of  condensing  them,  is  inadmissible,  since  there  is 
thus  great  danger  of  breaking  the  walls  of  the  cavity, 
and,  in  many  cases,  of  moving  the  filling  from  its 
place. 

1st  Mod. — The  palatal  wall  broken  away.     Fract- 


192  CLASSIFICATION   OF   DECAYED    CAVITIES. 

ures  of  this  kind  assume  different  forms;  sometimes 
triangular,  extending  from  the  border  of  the  cavity 
toward  the  center  of  the  tooth,  and  terminating  in  an 
acute  angle;  and  sometimes  the  border  of  the  cavity 
is  broken  away  irregularly,  or  so  as  to  form  part  of  a 
circle.  When  a  triangular  notch  is  broken  out  of 
the  wall,  the  operation  of  filling  may  be  performed  in 
one  of  two  ways  :  If  the  portions  of  the  wall  remain- 
ing at  each  side  of  the  fracture  are  thick  and  firm, 
they  may  be  left,  and  the  cavity  may  be  filled  up 
flush  with  both  the  proximal  and  the  palatal  surface 
of  the  tooth,  the  latter  being  thus  restored  with  gold 
to  the  extent  of  the  fracture  or  notch.  If,  however, 
the  remaining  portions  of  the  wall  are  frail,  they 
should  be  cut  away  till  a  border  is  reached  suffi- 
ciently firm  to  sustain  the  filling.  Such  cutting  will 
leave  the  notch  of  a  circular  form,  and,  in  many 
cases,  will  remove  almost  the  whole  of  the  inner  wall 
of  the  cavity.  As  the  decay  extends  toward  the 
center  of  the  tooth,  owing  to  the  concavity  of  its 
palatal  surface,  this  wall  becomes  very  thin ;  but,  in 
all  cases,  the  excavation  should  be  such  as  to  leave  a 
definite  wall,  though  it  be  but  slight,  all  along  that 
part  of  the  cavity.  In  such  a  case,  good  retaining 
points  must  be  made  in  the  cervical  wall,  since  the 
permanency  of  the  filling  will  depend  almost  entirely 
upon  these. 

The  surface  of  the  filling,  when  finished,  may  be 


FILLING    BY   CLASSES    AND    MODIFICATIONS.  193 

slightly  convex  from  one  lateral  wall  to  the  other; 
the  palatal  portion  of  the  surface,  from  the  point  of 
the  tooth  to  its  neck,  will  partake  of  the  curvature  of 
the  border  of  the  palatal  wall ;  but  the  anterior  por- 
tion will  be  only  flush  with  the  anterior  wall.  Much 
care  is  requisite  to  give  these  fillings  a  perfect  finish, 
on  account  of  the  irregularity  of  surface,  this,  in  many 
instances,  being  both  convex  and  concave.  As  a 
material  for  filling  these  cavities,  adhesive  gold  is 
much  to  be  preferred.  Indeed,  in  many  of  them,  it 
is  impossible,  with  nonadhesive  gold,  to  make  a  per- 
fect filling,  because  they  have  no  general  embracing 
form.  In  such  cases,  the  filling  should  be  introduced 
from  the  palatal  side  of  the  tooth. 

2d  Mod. — The  labial  wall  of  the  cavity  broken. 
The  fractures  of  this  wall  are  of  various  forms,  and 
of  extents  corresponding  with  the  friability  of  the 
enamel.  There  is  sometimes  the  triangular  notch, 
extending  far  toward  the  middle  of  the  tooth ;  and 
sometimes  there  are  two  or  three  small  notches ;  and 
still  in  other  cases,  almost  the  whole  of  the  wall  will 
be  broken  away  from  the  point  to  the  neck.  When 
there  is  simply  a  notch  in  the  enamel,  it  is  important 
for  the  appearance  of  the  tooth,  to  fill  it  up;  and 
when  there  is  any  prospect  of  success,  the  remaining 
portion  of  the  wall  being  retained,  the  operation  is  to 
be  performed  as  already  described  for  the  palatal 
wall.     It  will,  however,  in  many  cases,  be  necessary 


194  CLASSIFICATION    OF    DECAYED    CAVITIES. 

to  cut  away  part  of  the  remaining  portions  of  the 
wall,  leaving  the  general  form  of  the  border  some- 
what circular;  though  the  notch  form,  in  some  in- 
stances, is  not  wholly  obliterated. 

In  filling  this  kind  of  'cavitj^,  it  is  desirable  to  re- 
store as  much  as  possible  the  form  of  the  tooth.  The 
filling  should  be  built  out  from  the  border  of  the  wall 
almost  to  a  line  with  the  tooth's  original  proportions, 
so  that  the  whole  surface  of  the  filling  will  be  con- 
vex ;  and  should  be  finished  with  great  care,  the 
stipple  finish  being  preferable  for  that  part  exposed 
to  view. 

3d  Mod. — The  cavity  extending  almost  to  the  point 
of  the  tooth,  and  terminating,  or  cropping  out,  at  the 
surface.  In  the  preparation  of  this  cavity,  that  part 
next  the  point  of  the  tooth,  should  be  cut  in  enough 
to  form  a  definite  wall  there,  and  to  give  room  for 
sufficient  thickness  and  strength  in  that  portion  of 
the  plug.  Many  operators  attempt  to  fill  this  kind 
of  cavity  without  such  precaution,  terminating  that 
part  of  the  plug  in  a  thin,  sharp  edge.  The  method 
is  very  objectionable;  for  this  thin  edge  will  get  more 
or  less  separated  from  the  tooth,  and  foreign  sub- 
stances will  be  forced  under  it,  and,  becoming  vitiated, 
induce  decay.  Indeed,  a  defect  of  this  kind  is  a  sure 
precursor  of  the  destruction  of  the  filling.  The  intro- 
duction and  finish  of  the  filling  in  this  kind  of  cavity 
are  the  same  as  first  described  for  this  class ;  and  the 


FILLING    BY   CLASSES   AND    MODIFICATIONS.  195 

admonition  may  be  repeated,  that  there  be  left  no 
thin  overlappings  of  the  filling,  that  may  become 
changed  in  position. 

4th  Mod. — The  cavity  large,  and  the  lateral  walls 
thin  and  friable.  In  this  kind  of  cavity,  the  dentine 
is  almost  entirely  removed  from  the  lateral  walls, 
leaving  little  else  than  the  enamel  after  the  excava- 
tion of  the  decay.  These  walls  will,  of  course,  admit 
of  no  cutting  for  the  purpose  of  giving  them  a  more 
desirable  form.  The  cervical  wall  must  be  shaped 
with  special  reference  to  a  retention  of  the  filling,  to 
consolidate  which  the  requisite  pressure  must  be 
applied  almost  exclusively  toward  this  wall.  It 
requires  extreme  care  to  condense  the  gold  in  cavities 
of  this  kind,  and  adapt  it  to  the  lateral  walls,  without 
fracturing  them ;  and  various  methods  have  been  sua;- 
gested  to  prevent  such  an  accident.  Pluggers  with 
very  fine  points  are  recommended,  as  consolidating 
the  gold  with  much  less  pressure  than  would  be 
necessary  with  large-pointed  instruments.  But  it  has 
been  maintained  that  a  perfect  adaptation  of  the  gold 
to  the  inner  parts  of  these  walls  is  not  important, 
provided  the  adaptation  at  the  border  is  perfect."  It 
is  certain,  however,  that  a  filling  thus  imperfectly 
adapted,  is  not  so  good  as  though  the  gold  were  in 
contact  with  all  points  of  the  cavity;  and  besides,  the 
liability  of  fracturing  the  wall,  is  just  as  great  in  con- 
solidating at  the  border  as  within.     The  walls  may 


196  CLASSIFICATION    OF    DECAYED    CAVITIES. 

be  sustained  by  enveloping  the  tooth  to  the  borders 
of  the  cavity  with  some  material  perfectly  adaptable 
to  it,  and  capable  of  resisting  the  force  applied  in  the 
process  of  consolidation ;  as,  gutta  percha  or  plaster 
of  Paris.  If  the  former  is  employed,  it  should  be 
softened  by  warming,  moulded  upon  the  tooth,  and 
then  permitted  to  harden.  The  hardening  may  be 
facilitated  by  throwing  cold  water  on  it  from  a 
syringe.  It  is  then  to  be  trimmed  even  with  the 
border  of  the  cavity,  so  as  to  admit  the  filling.  If 
plaster  of  Paris  is  used,  it  should  be  the  best  article. 
Yet  gutta  percha  is  to  be  preferred.  But  a  better 
protection  than  either  may  be  made  of  cheoplastic 
metal,  taking  an  impression  of  the  tooth,  and  from 
that  moulding  the  shield ;  and  this  material  is  always 
to  be  recommended  in  extreme  cases.  In  these  fill- 
ings, when  the  enamel  is  clear  and  translucent,  the 
gold  will  be  visible  through  it.  To  obviate  this 
difficulty,  some  appropriate  substance  may  be  placed 
between  the  outer  wall  and  the  gold — some  sub- 
stance that  will  restore  the  natural  color  of  the  tooth. 
Quill,  horn,  paper,  and  asbestos  have  each  been  em- 
ployed for  this  purpose.  Horn  is,  perhaps,  the  best 
material,  as  it  can  generally  be  selected  of  a  suitable 
color.  A  thin  lamina  of  this  may  be  obtained  by 
pounding  a  piece  of  the  horn  for  a  few  moments, 
till  a  layer  is  detached ;  which  may  then  be  dressed 
down  to  the  proper  size,  softened  in  warm  water,  and 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  197 

placed  in  the  cavity  next  to  the  outer  wall,  yet  so  as 
not  to  extend  quite  to  the  border.  The  presence  of 
this  substance  makes  the  operation  of  filling  a  little 
more  complicated ;  but  the  horn,  being  softened,  is 
easily  pressed  to  the  side  of  the  cavity  and  conformed 
to  it ;  and  it  may  be  made  to  retain  its  place,  when 
first  introduced,  by  touching  it  at  one  or  two  points 
with  some  adhesive  material ;  or  it  may  be  made  very 
soft,  adjusted  in  the  cavity,  and  then  conformed  com- 
pletely to  the  wall  by  a  temporary  filling  of  gutta 
percha,  which,  after  having  chilled  and  stiffened,  may 
be  removed,  leaving  the  horn  thoroughly  adapted  and 
ready  for  the  gold. 

Fifth  Class. — Posterior  proximal  cavities  of  the 
molars  and  bicuspids.  These  are  separated  like 
anterior  proximal  cavities,  except  that,  ordinarily,  to 
open  them  up,  more  is  to  be  cut  from  the  tooth,  on 
account  of  the  greater  difficulty  of  approaching  and 
inspecting  the  cavity.  The  same  general  principles 
are  applicable  to  the  opening  of  this  class  of  cavities, 
as  to  that  of  the  third  class,  except  that  pressure  can 
not  be  as  frequently  employed,  since  the  cavity  will 
not  be  as  well  exposed  by  this  as  by  cutting,  nor 
rendered  so  easy  of  approach.  Indeed,  in  operating 
on  these  cavities,  the  use  of  the  mirror  is  often  neces- 
sary, it  being  impossible  to  obtain  a  direct  view  into 
them,  after  having  cut  away  all  that  it  is  admissible 
to  remove.     The  accessibility  of  these  cavities  will 


198  CLASSIFICATION    OP   DECAYED    CAVITIES. 

depend  on  circumstances  ;  such  as  the  location  of  the 
tooth,  its  inclination,  the  size  of  the  mouth,  the  flexi- 
bility of  the  muscles,  and  the  ability  of  the  patient  to 
open  the  mouth  and  keep  it  open.  Generally,  in 
operating  on  these  cavities,  for  the  removal  of  decay, 
the  formation,  and  the  filling,  curved  instruments 
will  be  required;  but  their  curvature  should  not  be 
greater  than  the  necessity  of  the  case  demands. 

The  cavity,  during  its  preparation,  must  be  fre- 
quently examined.  Its  general  form,  and  the  size, 
kind,  and  location  of  the  retaining-points  will  be  the 
same  as  in  class  third.  The  lateral  walls,  if  the 
cavity  is  not  too  large,  should  be  made  parallel  with 
each  other;  the  undercutting  at  the  crown  wall  will 
be  less  than  in  anterior  proximal  cavities ;  and  the 
cervical  wall  should  have  the  same  general  form  as 
in  other  cases.  In  this  latter  there  should  be  made, 
at  different  angles,  pits  for  retaining-points — three,  if 
the  tooth  is  a  molar,  and  two  if  a  bicuspid.  For 
making  these  pits,  Merry's  drill  will  be  found  more 
convenient  than  any  other  instrument. 

Preparatory  to  introducing  the  filling,  the  same 
appliances  should  be  used  to  protect  the  cavity  from 
moisture,  that  have  been  indicated  in  modification 
first  of  class  third.  Crystal  gold  makes  a  better  be- 
ginning for  these  fillings  than  foil;  and  hence  the 
retaining-points  should  be  filled  up  with  it,  and  an 
attachment  made  from  one  to  the  other;  on  which 


FILLING   BY    CLASSES  AND    MODIFICATIONS.  199 

foundation  adhesive  foil  may  be  built,  almost  up  to 
the  crown  wall  of  the  cavity,  and  then  the  remaining 
portion  filled  from  the  bottom  to  the  orifice.  These 
fillings  should  have  a  single  plain  surface,  which  will 
be  at  a  greater  or  less  angle  with  the  axis  of  the 
tooth,  according  to  the  greater  or  less  portion  cut 
away  in  the  separation.  It  is  impracticable  to  build 
these  fillings  up  as  some  of  those  in  the  anterior 
proximal  cavities  may  be,  because  of  the  difficulty  of 
thoroughly  consolidating  and  finishing  their  proximal 
portions,  especially  near  the  neck  of  the  tooth ; 
though  the  difficulty  is  somewhat  obviated  by  placing 
a  piece  of  polished  metal,  of  the  proper  thickness, 
back  of  the  cavity,  against  the  adjoining  tooth,  intro- 
ducing the  filling,  and  consolidating  it  firmly  up  to 
this  piece  of  metal :  the  lost  portion  of  the  crown 
being  thus  restored,  the  metal  is  then  removed,  and 
the  filling  dressed  off  and  finished  in  the  manner  de- 
scribed heretofore.  The  labor,  tedium,  and  difficulty 
of  manipulation  are  increased  the  farther  back  in  the 
mouth  the  decay  is  situated.  The  modifications  of 
this  class  are  the  same  as  those  of  the  third  class  of 
cavities,  and,  except  the  second  modification,  are  sus- 
ceptible of  the  same  methods  of  filling. 

Special  Cases. — The  first  case  that  we  shall  con- 
sider here,  consists  in  a  complication  of  proximal 
decay  with  decay  on  the  buccal  or  palatal  portion  of 
the  tooth,  thus  undercutting  one  of  the  crown  angles. 


200  CLASSIFICATION    OF   DECAYED    CAVITIES. 

Sometimes  these  decays  are  on  both  sides,  in  the 
form  of  transverse  grooves,  meeting  at  the  corner  of 
the  tooth.  In  such  cases,  if  the  pendent  crown 
angle  of  the  tooth  is  firm  and  strong,  the  cavities 
may  be  formed  in  the  proper  manner,  and  filled 
without  interfering  with  the  masticating  portion  of 
the  tooth  at  all;  but,  if  the  pendent  portion  is  friable, 
it  should  be  cut  away,  and  the  corner  built  up  with 
gold.  The  method  of  forming  the  part  to  be  filled 
will  depend  on  the  extent  of  the  decay.  When  this 
is  large,  a  greater  number  of  retaining-points  will  be 
required  than  when  it  is  small ;  and  these  should  be 
located  at  such  parts  as  will  make  them  most  tena- 
cious of  the  gold,  and  least  subversive  of  the  strength 
of  the  tooth.  The  filling  may  be  built  up  so  as  to 
restore  the  original  form  of  the  tooth,  thus  presenting 
three  surfaces,  the  proximal,  the  buccal  or  palatal, 
and  the  masticatory;  or,  it  may  be  made  with  a  single 
slightly  convex  surface,  adapted  and  finished  most 
completely  at  all  its  borders.  This  kind  of  filling 
can  be  made  only  with  adhesive  gold. 

The  palatal  portion  of  the  crown  broken  away,  leav- 
ing the  outer  portion  standing — nerve  not  exposed. — The 
tooth,  in  such  case,  is  decayed  away  so  that  the  floor 
of  solid  dentine  is  near  the  margin  of  the  gum,  the 
labial  third  of  the  crown  still  standing.  The  decay 
having  been  all  removed,  four  or  five  little  pits 
should  be  made  on  this  floor,  as  near  its  circumfer- 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  201 

ence  as  practicable ;  and  a  small  groove  may  be  cut 
from  one  of  these  pits  to  an  other  all  round  near  the 
edge  of  the  floor.  Then  two  little  pits  should  be 
made  at  the  base  of  the  standing  portion  of  the 
crown,  if  they  can  be,  without  interfering  with  the 
pulp,  provided  this  is  still  living.  The  decayed  part 
thus  prepared,  a  sufficient  shield,  in  the  form  of  pa- 
per, folds  of  napkin,  etc.,  is  to  be  thrown  round  the 
tooth,  to  protect  it  against  moisture  during  a  pro- 
tracted operation  :  in  this  particular  great  care  is 
necessary. 

For  building  up  a  crown  of  this  kind,  only  adhesive 
gold  can  be  used ;  and  this  should  be  of  the  best  prep- 
aration, and  in  the  most  perfect  condition,  since  it 
is  important  that  the  different  portions  of  the  filling 
be  most  thoroughly  united.  The  instruments  em- 
ployed in  the  operation  should  be  of  the  best  kind 
and  in  the  best  condition,  the  serrate  points  being 
definite  and  sharp,  though  not  too  long :  those  with 
four,  six,  or  eight  points  may  be  advantageously  used 
for  packing  the  gold.  But  care  must  be  exercised 
lest  these  fine  points  be  turned ;  for  when  that  is  the 
case,  the  instrument  is  liable  to  displace  the  portion 
of  gold,  and  thus  break  up  its  first  attachment  during 
the  process  of  consolidation;  and  when  this  is  broken, 
the  piece  of  gold  can  not  again  be  made  to  adhere  as 
perfectly  as  before. 

With  every  thing  thus  in  readiness,  the  retaining- 


202  CLASSIFICATION    OF   DECAYED    CAVITIES. 

points  are  all  to  be  rilled,  the  gold  extending  from 
one  to  the  other ;  which  is  then  to  be  built  all  over 
the  bottom  of  the  part  to  be  restored,  projecting  a 
little  beyond  the  periphery,  and  being  perfectly  con- 
solidated there,  and  kept  somewhat  higher  round  the 
border  than  in  the  center.  The  gold  should  be  built 
on  in  this  manner  till  the  crown  is  large  enough, 
after  dressing,  to  give  the  desired  size  and  form.  In 
finishing  up,  the  aim  should  be,  to  restore  as  perfectly 
as  possible  the  lost  form  of  the  tooth ;  the  mastica- 
ting surface,  the  lost  cusp,  the  antagonism,  and  all. 
The  adaptation  of  the  gold,  too,  to  the  standing  por- 
tion of  the  crown  should  be  most  complete ;  imperfec- 
tion in  this  respect  impairs  the  appearance  of  the 
work,  and  jeopardizes  the  security  of  the  operation. 

Occasionally  the  crown  of  a  molar  tooth  is  found 
decayed  off  all  round,  almost  to  the  margin  of  the 
gum,  the  pulp  having  previously  receded  so  as  not 
to  be  exposed.  It  is,  in  such  case,  desirable  to  re- 
store the  lost  portion  of  the  crown,  and  make  a  mas- 
ticatory surface  such  as  shall  antagonize  properly 
with  the  teeth  of  the  opposite  jaw.  As  yet,  there  is 
no  other  method  of  accomplishing  this,  than  by  build- 
ing it  up  with  gold — adhesive  gold  foil  or  crystal 
gold.  In  the  preparation  for  this  crown  of  gold,  the 
edge  should  be  dressed  smooth  and  even  all  round 
the  tooth ;  .then  six  or  eight  deep  pits  should  be  made 
at  different  angles  about  on  the  base  thus  prepared  ; 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  203 

and  they  should  be  bored  with  a  drill  larger  than  is 
commonly  used  for  retaining-points.  These  pits  may 
be  slightly  enlarged  within.  The  method  of  building 
up  the  crown  is  just  the  same  as  that  described  for 
building  up  part  of  a  crown,  the  pits  being  first  filled, 
then  joined  together,  and  the  gold  extended  all  over 
the  part  to  be  covered  by  the  filling.  In  extending 
the  gold  from  a  retaining-point  or  points,  it  is  neces- 
sary to  build  up  to  a  considerable  thickness  above  the 
orifice  of  the  pit.  The  portion  of  gold  extending 
along  on  the  tooth  from  the  pit,  should  be  quite  thick 
and  firm,  so  as  not  to  curl  up  from  its  position,  on 
the  addition  of  subsequent  portions.  Every  particle 
of  gold,  indeed,  should  be  so  manipulated,  that  it  will 
securely  maintain  its. first  position.  The  permanency 
of  the  operation  will  depend  very  much  upon  this 
precaution.  The  gold  should  extend  somewhat  be- 
yond the  circumference  of  the  tooth  all  round,  in 
order  to  a  thorough  adaptation  and  finish. 

The  foundation  thus  prepared,  and  kept  free  from 
moisture,  the  crown  is  easily  built  up  by  the  ordinary 
method  of  packing  the  gold.  Any  desired  shape  can 
be  given  to  this  artificial  crown;  but,  of  course,  that 
which  most  nearly  resembles  the  form  of  the  natural 
crown,  is  in  all  cases  most  nearly  perfect.  The  masti- 
cating surface  of  this  gold  crown  is  to  be  formed  from 
the  indications  given  by  the  antagonizing  teeth. 
Such  crowns  will  wear  for  years,  and  perform  all  the 


204  CLASSIFICATION    OP    DECAYED    CAVITIES. 

functions  of  the  natural  organs.  Artificial  crowns  of 
this  kind  have  been  attached  to  the  tooth,  by  screw- 
ing into  the  pits  small  pieces  of  gold  wire  at  different 
angles,  and  then  building  up  round  and  between 
them  with  the  gold  foil,  on  the  principle  already 
described,  thus  making  these  wires  serve  as  so  many 
anchors  for  fastening  the  work.  This,  however,  is  a 
less  efficient  method  than  the  one  first  described, 
since  there  is  no  cohesive  attachment  of  the  foil  to 
these  gold  anchors,  and  it  is  retained  in  place  only 
by  the  mechanical  arrangement  of  the  wires ;  but  by 
barbing  or  roughening  them,  or  giving  them  abrupt 
curves,  they  may  be  made  to  retain  the  crown  well, 
if  it  is  thoroughly  consolidated  and  united.  But  the 
method  of  anchoring  with  foil,  as  before  observed,  is 
always  to  be  preferred,  since  by  this  there  is  a  weld- 
ing of  the  entire  mass,  and  an  anchorage,  too,  quite 
sufficient  in  all  cases  to  retain  it  in  its  place. 

Filling  large  cavities  on  the  labial  surfaces  of  (lie 
superior  incisors. — These  cavities  are  usually  super- 
ficial, and  frequently  coextensive  with  a  considerable 
part  of  the  surface  of  the  tooth.  A  method  of  filling 
them,  somewhat  novel,  though  not  without  merit,  has 
recently  been  introduced  to  the  notice  of  the  profes- 
sion by  Dr.  Volck,  it  having  been  first  suggested  to 
him,  however,  by  Dr.  Maynard.  It  consists  in  filling 
up  the  cavity  principally  with  a  piece  of  enamel,  as 
near  the  color  of  the  tooth  as  possible.     The  cavity, 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  205 

when  nearly  round,  should  be  formed  with  a  wheel  bur 
of  the  proper  size ;  and  after  having  been  thus  reamed 
out,  a  slight  undercutting  should  be  made  all  round 
with  an  excavator.  Then  a  piece  of  enamel  being  se- 
lected, it  is  dressed  to  a  proper  thickness,  which  should 
be  slightly  greater  than  the  cavity's  depth,  and  to  a 
perfectly  circular  form,  its  size  being  such  as  to  let  it 
drop,  with  a  little  play,  into  the  cavity,  and  the  edge 
of  it  being  beveled  from  without.  For  fastening  this 
in  the  cavity,  roll  a  strip  of  several  thicknesses  of 
gold  foil  round  its  edge,  and  add  as  much  as  can  be 
forced  in  with  it;  set  it  all  in  place  in  the  cavity, 
and  then  condense  the  gold  down  into  the  groove  all 
round  with  a  thin-pointed  plugger,  more  gold  being 
added,  if  necessary,  to  fill  the  groove  completely  full. 
Afterwards,  with  the  file,  stone,  and  burnisher,  dress 
off  the  whole  to  a  proper  level  with  the  surrounding 
tooth,  finishing  very  carefully  with  the  burnisher. 
The  unsightliness  of  a  large  gold  filling  on  a  front 
tooth  is  thus  obviated,  no  metal  except  that  compo- 
sing the  ring  of  attachment  in  the  groove  being  ex- 
posed to  view.  It  is  a  beautiful  operation,  and  one 
whose  successful  accomplishment  will  require  con- 
siderable constructive  talent  and  skill. 


CHAPTER  VIII. 

PATHOLOGICAL   CONDITIONS. 

Hitherto,  in  our  consideration  of  the  treatment  of 
caries,  we  have  postponed  the  subject  of  the  vitality 
and  pathology  of  the  teeth  altogether.  It  now  re- 
mains to  describe  the  diseased  conditions  to  which 
the  teeth  are  subject,  and  the  treatment  which  those 
respective  conditions  indicate.  This  is  an  important 
department  of  the  practice,  since  upon  skill  in  this, 
as  well  as  upon  the  manner  of  performing  the  work, 
the  success  of  the  operation  depends. 

Premising  that  our  remarks  on  this  branch  of  the 
subject  are  predicated  on  the  fact  admitted,  that  the 
teeth  possess  vitality,  we  proceed  to  consider  the 
pathological  conditions  to  which,  in  common  with  all 
organic  matter,  they  are  liable.  There  is  but  one 
diseased  condition  of  living  dentine  that  presents  any 
considerable  difficulty  in  the  ordinary  operation  of 
filling  teeth,  and  that  is,  inflammation,  or  exalted 
sensibility.  This  condition  was  referred  to  in  the 
remarks  on  the  treatment  of  caries,  as  being  one  that 


PATHOLOGICAL    CONDITIONS.  207 

most    generally    accompanies    decays   of    the    teeth. 
Whether  or  not  this  affection  is  real  inflammation,  is 
a  point  that  has  been  considerably  controverted ;  and 
the  assertion  has  been  made,  that  it  is  of  no  conse- 
quence whether  it  is  or  not,  provided  we  understand 
the  true   method  of  treating  it.     This,  however,  is 
not  to  be  so  readily  conceded ;  for  the  confession  that 
we  do  not  know  what  to  call  a  thing,  generally  im- 
plies an  ignorance  of  its  character  and  phenomena  : 
while    the    term    inflammation    conveys    a   definite 
notion,  the   phrase  exalted   sensibility  is  very  vague 
in  meaning.     That    it   is   true  inflammation,  is  the 
opinion  of  our  best  dental  writers.     The  dentine  is 
endowed  with  the  functions  of  absorption,  nutrition, 
and  secretion — characteristics  that  always    imply  a 
susceptibility  of  inflammation.     In   inflammation  of 
the  soft  parts,  there  are  present  various  indications ; 
as,  pain,  redness,  swelling,  and  increased  heat.     But 
in  dentine,  on  account  of  its  peculiar  structure,  all 
these  indications  can  not  be  manifested  :  for  instance, 
redness,    since   the    red    globules    do    not   circulate 
through  it ;  nor  swelling,  since  the  structure  is  too 
dense ;  nor  perceptibly  increased  heat,  since  the  circu- 
lation is  of  too  low  a  grade.     But,  one  of  the  most 
definite  indications  of  inflammation,  namely,  exalted 
sensibility,  is  present  here  in  all  its  force.    And  there 
are   various  other   circumstances    that  indicate  this 
condition    to    be  real  inflammation :    the   same   irri- 


208  PATHOLOGICAL     CONDITIONS. 

taring  causes  that  induce  inflammation  in  the  more 
highly  organized  parts,  occasion  it  in  the  living  den- 
tine ;  this  condition  of  the  teeth  is  always  affected  by 
a  general  inflammatory  diathesis,  and  their  sensitive- 
ness, when  there  is  this  general  tendency  to  inflam- 
mation, is  always  increased,  and  local  treatment  in 
such  case  will  commonly  be  inefficient ;  a  modifica- 
tion of  such  a  condition  of  the  system  produces  a 
very  corresponding  change  in  the  affected  teeth  ;  and 
those  remedial  agents  which  are  employed  in  the 
topical  treatment  of  inflammation  elsewhere,  are  suc- 
cessfully used  in  the  treatment  of  inflamed  dentine. 
From  all  these  circumstances,  the  conclusion  is  almost 
irresistible,  that  this  affection  of  the  teeth  is  a  real 
inflammation. 

As  it  has  been  already  remarked,  the  only  definite 
and  direct  indication  of  inflammation  of  the  dentine, 
is  exalted  sensibility ;  though  this  is  not  an  immedi- 
ate consequence  of  that  condition,  independent  of 
external  circumstances ;  for  the  pain  resulting  directly 
from  inflammation  in  the  soft  parts,  is  not  experi- 
enced here,  by  reason  of  the  low  grade  of  vitality  and 
the  feeble  circulation.  But  the  teeth,  in  a  state  of 
inflammation,  will  suffer  pain  when  subjected  to  sud- 
den variations  of  temperature,  whether  induced  by 
the  air,  by  fluids,  or  by  any  hard  substance;  and 
when  subjected  to  the  influence  of  agents  that  irri- 
tate the  nerve-tissue  anywhere,  such  as  acids,  some 


PATHOLOGICAL    CONDITIONS.  209 

alkalies,  salts,  and  sweets.  In  regard  to  degree, 
extent,  and  location,  this  affection  exhibits  a  variety 
of  manifestations ;  in  degree,  from  the  most  mild  to 
the  most  intense — sometimes  fixed  at  a  uniform  pitch 
of  pain,  and  sometimes  passing  through  the  gamut  of 
torture  up  to  the  most  acute  anguish.  The  character 
of  the  affection  is  modified  by  differences  in  the 
organic  structure  of  the  teeth,  those  most  vascular 
and  most  highly  organized  being  most  readily  and 
most  extensively  involved;  and  therefore  the  teeth 
of  the  young  are  generally  more  liable  to  it  than 
those  of  the  old.  So,  too,  persons  of  a  plethoric  or  a 
strumous  habit,  as  well  as  those  in  a  febrile  condi- 
tion, are  peculiarly  predisposed  to  this  affection. 
Sometimes  irritation  or  disturbance  of  other  organs  of 
the  system,  sympathetically  or  secondarily  induce 
inflammation  of  the  dentine.  Uterine  irritation  fre- 
quently does  so ;  and  hence,  during  pregnancy  or  a 
protracted  suppression  of  the  catamenia,  the  teeth  are 
very  liable  to  be  thus  affected,  and,  if  decayed,  to 
become  very  sensitive. 

Inflammation  of  the  dentine  will  sometimes  be 
exhibited  in  various  degrees  in  different  teeth  in  the 
same  mouth  at  one  time.  This  is  owing  to  differ- 
ences in  the  organic  structure  of  teeth  developed  at 
different  periods  of  life,  to  differences  of  their  loca- 
tion in  the  month,  and  to  differences  of  exposure  to 
those  agencies  which  are  apt  to  induce  the  condition. 

o 


210  PATHOLOGICAL    CONDITIONS. 

As  to  the  extent  of  this  inflammation,  it  may  be  con- 
fined to  a  thin  lamina  of  bone  immediately  beneath 
the  decomposed  portion,  or  may  extend  deep  into  the 
body  of  the  tooth,  and,  indeed,  in  some  cases,  pervade 
the  dentine  of  the  entire  crown.  This  latter  extent, 
however,  it  is  not  likely  to  have,  unless  it  is  the 
result  of  a  general  predisposition  :  if  it  is  produced 
by  local  causes,  it  will  not,  in  general,  penetrate  very 
deeply  into  the  dentine.  Most  commonly,  the  great- 
est sensitiveness  is  at  the  union  of  the  dentine  with 
the  enamel ;  but,  sometimes,  it  is  confined  to  a  small 
point  within  the  cavity,  either  because  there  is  a 
concentration  of  nerve-fibrils  there,  or  because  there 
has  been  a  determination  of  the  irritating  influences 
to  that  point — the  former  being  the  most  probable 
cause.  The  greatest  sensitiveness,  as  already  re- 
marked, is  generally  at  the  surface  of  the  dentine, 
because  that  is  the  termination  of  the  nerve-fibrils 
which  ramify  the  dentine,  and  wherever  nerve-fiber 
terminates,  there  always  we  may  look  for  exalted 
sensibility.  Hence  it  is,  that  decay  of  the  teeth  is 
often  found  to  be  more  sensitive  in  its  incipient 
stages,  than  when  it  has  become  more  advanced. 

Treatment  of  Inflamed  Dentine. — There  are  several 
methods  of  treatment  that  might  be  employed  to 
remedy  this  condition.  In  many  cases,  where  time 
and  circumstances  will  permit,  a  removal  of  all  irri- 
tating   agents    from  the   affected  parts,   will  enable 


PATHOLOGICAL   CONDITIONS.  211 

nature  alone  to  effect  a  restoration  to  health.  All 
decomposed  dentine  is  to  be  cleaned  from  the  cavity, 
every  exciting  influence  in  it  withdrawn  or  neutral- 
ized, and  the  cavity  itself  perfectly  filled  with  some 
nonconducting  material,  so  as  entirely  to  exclude  all 
foreign  substances.  This  material  may  be  gutta 
percha  or  Hill's  Stopping; — and  this,  in  the  property 
of  nonconduction,  is  superior  to  any  other ; — or,  in 
some  cases,  it  may  be  tin  or  gold ;  but,  when  either 
of  these  is  employed  for  the  purpose  of  such  tempo- 
rary filling,  some  nonconducting  substance  should  be 
placed  between  it  and  the  sensitive  dentine.  The 
length  of  time  necessary  for  a  restoration  of  the 
affected  part,  under  this  treatment,  will  be  much 
varied  by  circumstances.  The  cases  susceptible  of 
this  kind  of  treatment  are  those  in  which  there  is  no 
constitutional  predisposition,  in  which  the  vitality  is 
strong,  and  the  recuperative  power  vigorous.  When 
the  temporary  fillings  are  made  of  metals,  the  patient 
should  be  careful  to  protect  them  from  sudden  changes 
of  temperature.  For  such  fillings,  in  case  they  are 
required  but  for  a  short  time,  a  lock  of  cotton  satu- 
rated with  a  solution  of  gutta  percha  and  chloroform, 
may  be  used. 

But,  in  cases  in  which  the  vitality  is  low,  the 
affection  chronic,  the  exciting  cause  highly  irritating, 
and  the  general  diathesis  inflammatory,  nature,  un- 
aided, will  not  effect  a  cure.     In  such  circumstances, 


212  PATHOLOGICAL   CONDITIONS. 

therapeutic  treatment  is  indicated.  The  agents  em- 
ployed in  topical  treatment  may  be  divided  into  two 
classes :  first,  resolvents,  or  those  which  have  for 
their  object  an  entire  restoration  to  health  of  the 
part  affected ;  and  second,  escharotics,  or  those  which 
have  for  their  object  the  death  of  a  portion  or  all  of 
the  diseased  part.  The  former  class  of  agents  is  of 
course  preferable,  when  their  object  can  be  promptly 
accomplished  by  their  use,  and  especially  preferable 
to  those  agents  which  endanger  the  vitalitv  of  the 
whole  tooth.  In  very  many  cases  in  which  topical 
applications  are  indicated,  constitutional  treatment  is 
also  required;  and  this  should  be  of  an  antiphlogistic 
character.  The  immediately  adjacent  parts,  too,  as 
the  gums,  the  mucous  membrane,  etc.,  should  be 
carefully  regarded.  Indeed,  treatment  of  the  gums 
by  counter  irritation,  depletion,  and  various  prepara- 
tions, such  as  the  conditions  may  indicate,  will  often 
be  found  prerequisite  to  a  successful  treatment  of  sens- 
itive dentine  by  topical  applications. 

There  are  very  few  agents  used  simply  as  resolv- 
ents. The  properties  characteristic  of  this  class  of 
agents  are  tonic,  stimulant,  sedative,  and  astringent. 
Tincture  of  capsicum  may  fitly  represent  the  stimu- 
lant, Peruvian  bark  the  tonic  and  astringent,  gum 
myrrh  the  tonic,  and  opiates  the  sedative  principle. 
Astringents,  stimulants,  and  sedatives  all  tend  to 
counteract   the   inflammation.     The    agents   of  this 


PATHOLOGICAL   CONDITIONS.  213 

class  are  not  very  extensively  used  in  the  treatment 
of  dentine,  not  because  they  are  not  ultimately  effi- 
cient, but  because  their  action  is  less  vigorous  than 
that  of  some  other  agents.  When,  however,  time 
and  circumstances  will  permit,  mild  treatment,  if  effi- 
cient, is  to  be  preferred. 

But  there  are  many  cases  in  which,  for  want  of 
time,  something  more  rapid  in  its  action  is  required. 
Of  this  character  is  the  second  class  of  therapeutic 
agents,  namely,  escharotics,  or  those  which,  by  their 
action,  destroy  a  portion  of  the  tissue  with  which 
they  come  in  contact.  It  may  be  well  to  notice, 
separately,  the  preparations  commonly  used  for  this 
purpose. 

Tannin,  or  Tannic  Acid. — This  is  the  active  prin- 
ciple of  vegetable  astringents,  and  is  found  most 
abundant  in  nutgalls.  It  unites  with  albumen,  fibrin, 
and  gelatin,  forming  with  them  insoluble  tannates. 
Its  medicinal  influence  is  almost  necessarily  topical, 
since  the  promptness  of  its  action  on  albuminous  sub- 
stances, and  the  insolubility  of  its  compounds  with 
them,  prevent  its  admission  into  the  general  circula- 
tion. The  action  of  tannin  on  dentine  has  been 
already  explained.  Either  its  aqueous  or  its  alcoholic 
solution  may  be  employed,  the  latter  being  the  better 
and  more  convenient  preparation.  Where  tannin  is 
applied  to  dentine,  there  is  formed  a  tannate  of  albu- 
men, which,  being  insoluble,  protects  from  irritation, 


214  PATHOLOGICAL    CONDITIONS. 

and  probably  incites  to  healthy  condition,  the  living 
parts  beneath  it. 

Creosote,  or  Carholic  Acid. — Formerly,  creosote  was 
obtained  by  distillation  of  wood,  and  differed  some- 
what from  that  in  present  use,  which  is  prepared  by 
distillation  of  coal  tar — this  latter  being  the  genuine 
carbolic  acid.  It  dissolves  freely  in  alcohol  or  ether, 
and  sparingly  in  water ;  and  its  action  may  therefore 
be  modified  by  dilution.  Creosote  produces  its  caustic 
effects  by  its  affinity  for  albumen  and  gelatin,  with 
which  it  forms  insoluble  compounds;  and  from  its 
modus  operandi,  it  is  evident  that  the  popular  opinion 
that  it  promotes  decay  of  the  teeth,  is  an  error. 

Nitrate  of  Silver. — This  salt  is  a  powerful  caustic, 
whether  applied  to  soft  parts  or  to  bony  tissue.  Its 
action  is  somewhat  complex.  Nitric  acid  is  liberated 
by  the  decomposition  of  the  salt,  when  in  contact  with 
organic  matter.  Nitrate  of  silver  has  a  strong  affinity 
for  albumen,  uniting  with  it  without  difficulty ;  and 
the  compound  thus  formed,  is  soluble  in  nitric  acid  or 
in  a  dilution  of  chlorid  of  sodium.  When  the  nitrate 
is  applied  to  the  skin,  the  immediate  result  is  a 
whitish  mark,  caused  by  a  union  of  the  salt  with  the 
albumen  of  the  cuticle ;  but  this  soon  turns  black,  by 
the  reduction  of  the  salt  and  the  decomposition  of  the 
silver ;  when,  for  each  atom  of  silver  set  free,  there  is 
liberated  an  equivalent  of  nitric  acid.  There  is  here, 
then,  an  agent  that  acts  promptly  on  the  gelatinous 


PATHOLOGICAL  CONDITIONS.  215 

portion  of  the  tooth,  destroying  its  vitality  to  the  ex- 
tent of  the  combination  which  takes  place,  and  that, 
by  the  decomposition  of  part  of  the  salt,  and  the  con- 
sequent liberation  of  part  of  the  acid,  also  acts  with 
energy  on  the  calcareous  portion.  The  compound 
formed  by  the  nitrate  with  the  organic  constituents 
of  the  tooth,  is  insoluble  except  with  a  few  substances, 
and  therefore  protects  the  subjacent  parts;  and  the 
precipitation  of  the  reduced  oxyd  on  the  surface, 
affords  some  additional  protection.  The  insolubility 
of  the  compound  above  mentioned,  prevents  an  ab- 
sorption of  the  nitrate  by  the  dentine,  and  renders 
its  action  necessarily  superficial.  When  the  nitrate 
is  neutralized  by  a  union  with  it  of  an  equivalent  of 
the  constituents  of  the  dentine,  no  further  chemical 
action  is  possible.  The  compound  formed  by  this 
union  is  soluble  in  a  dilution  of  the  nitrate  ;  and  if 
this  be  applied  in  too  great  a  quantity,  there  may  be 
a  larger  loss  of  substance  than  is  desirable  or  at  all 
necessary ;  for,  as  long  as  free  nitrate  remains  in 
solution  in  the  cavity,  the  insoluble  compound  is  not 
precipitated,  and  the  surface  is  therefore  exposed  to 
the  continued  action.  It  is  preferable  to  employ  the 
nitrate  in  the  solid  state,  or,  when  this  is  not  practi- 
cable, in  a  concentrated  solution  and  small  quantity, 
rather  than  in  a  copious  dilution  and  repeated  appli- 
cation. 

From  the  observations  already  made,  it  is  quite 


216  PATHOLOGICAL    CONDITIONS. 

evident  that  no  harm  can  result  to  the  tooth  from  a 
proper  application  of  this  agent,  beyond  the  portion 
of  it  immediately  acted  upon.  The  nitrate  can  not 
be  absorbed  by  dentine,  but  it  stimulates  the  sub- 
jacent dentine  to  more  healthy  action  ;  though  some 
maintain  that  it  is  not  as  efficient  in  this  respect  as 
some  proper  chlorid.  It  acts  to  a  greater  depth  than 
tannin  or  creosote,  but  not  so  deep  as  chlorid  of  zinc, 
nor  with  so  much  pain. 

Chlorid  of  Zinc. — This  is  more  generally  used  in 
the  treatment  of  sensitive  dentine  than  any  other 
caustic.  It  exerts  an  antiseptic  and  disinfectant,  as 
well  as  an  escharotic  influence.  In  its  operation  it 
decomposes,  the  chlorine  affinitizing  wTith  the  animal 
and  the  calcareous  elements  of  the  dentine.  It  is 
milder  in  solution  than  in  solid,  and  less  efficient  and 
less  painful.  It  is  soluble  in  water,  alcohol,  ether,  or 
chloroform.  The  etherial  and  the  chloroformal  solu- 
tions are,  in  their  action,  least  painful  of  all  the  forms 
in  which  this  chlorid  is  applied.  The  union  of  this 
agent  with  the  gelatinous  constituent  of  the  tooth  is 
also  more  prompt  in  solution  than  in  solid.  The 
ether  and  the  chloroform  may  lessen  the  pain  by 
their  anesthetic  influence.  In  the  use  of  the  chlorid 
or  any  other  active  caustic,  it  is  important  to  bear  in 
mind  the  exalted  vitality  which  follows  its  applica- 
tion ;  and  the  operation  should  be  immediately  per- 
formed.    In  the  teeth  of  young  persons,  or  those  in 


PATHOLOGICAL     CONDITIONS.  "217 

which  the  animal  constituent  greatly  predominates, 
the  vitality  will  be  more  promptly  aroused  than  in 
those  of  an  opposite  texture,  and  the  change,  too,  will 
be  greater.  If  the  inflammation  is  confined  to  a  thin 
lamina,  it  will  be  almost  instantly  allayed  by  the 
application  of  the  chlorid,  and  the  cavity  may  be  ex- 
cavated, as  though  there  had  never  been  any  exalted 
sensibility ;  but  if  the  operation  be  delayed  any  con- 
siderable time,  the  tooth  will  often  be  found  in  a 
worse  condition  for  excavating  than  before  the  appli- 
cation. The  remarks  on  absorption  under  the  head 
of  nitrate  of  silver,  apply  with  equal  force  here:  there 
is  not  the  least  danger  from  this  source;  indeed,  there 
can  be  none,  even  when  the  chlorid  is  applied  to  the 
soft  parts. 

Terchlorid  of  Gold. — Of  this  preparation  the  ethe- 
rial  solution  only  has  been  employed.  This  acts  with 
great  promptness  on  the  dentine,  forming  an  insoluble 
compound  with  the  gelatinous  elements,  and  the 
chlorine  of  it  forming  also  a  combination  with  the  cal- 
careous portion.  On  account  of  the  promptness  with 
which  this  agent  operates,  neither  the  pain  nor  the 
disturbance  of  the  subjacent  parts  caused  by  it,  is 
great.  This  substance  is  very  liable  to  decompo- 
sition. By  exposure  to  air  or  light,  the  gold  is  pre- 
cipitated in  the  metallic  form.  But,  protected  from 
these,  it  may  be  preserved  for  a  long  time.  This 
agent  will  not  be  absorbed  by  the  dentine. 


218  PATHOLOGICAL    CONDITIONS. 

Arsenious  Acid. — The  modus  operandi  of  this  agent 
is  involved  in  great  obscurity.  In  regard  to  its  topical 
action,  Professor  Bache,  says :  "  Arsenious  acid,  when 
it  produces  the  death  of  a  part,  does  not  act,  strictly 
speaking,  as  an  escharotic ;  it  destroys  the  vitality  of 
the  organized  structure,  and  its  decomposition  is  the 
consequence.  The  true  escharotic  acts  chemically, 
producing  a  decomposition  of  the  part  to  which  it  is 
applied;  a  state  incompatible  with  life."  Pereira 
says  :  "  Though  employed  as  a  caustic,  yet  the  nature 
of  its  chemical  influence  on  the  animal  tissue,  is  un- 
known ;  hence  it  is  termed  by  some  a  dynamic  caus- 
tic." Its  escharotic  power  certainly  bears  no  propor- 
tion to  its  vitality ;  but  it  is  probable  that  it  forms  defi- 
nite compounds  with  some  of  the  constituents  of  living 
tissue  ;  and  if  so,  these  compounds  appear  to  be  readily 
and  rapidly  decomposed,  so  that  the  acid  becomes 
again  free  to  attack,  with  similar  results,  the  sub- 
jacent parts.  The  topical  application  of  arsenic  is 
liable  to  be  followed  by  constitutional  effects. 

All  dentists  are  aware  of  the  fact  that  a  tooth-pulp 
may  be  destroyed  by  arsenic,  through  a  wall  of  con- 
siderable thickness.  To  accomplish  this,  the  agent 
must  in  some  way  penetrate  the  substance  of  the 
dentine ;  and  the  vitality  of  the  dentine  is  destroyed 
so  far  as  it  is  thus  penetrated  ;  indeed,  the  vitality  of 
the  whole  crown  of  the  tooth,  both  dentine  and  pulp, 
is  often  destroyed  by  the  use  of  this  remedy,  applied 


PATHOLOGICAL    CONDITIONS.  219 

even  to  a  small  cavity.  Exalted  sensibility  of  den- 
tine is  subdued  by  this  agent,  more  through  its  vital, 
than  through  its  chemical  energy.  It  is  very  soluble 
in  creosotes  and  all  similar  oils,  and,  to  a  considerable 
extent,  in  alcohol  and  water.  It  is  absorbed  much 
more  rapidly  in  solution  than  in  solid ;  and  the  more 
vascular  the  dentine,  the  more  rapid  and  extensive 
will  be  the  absorption  ;  and  on  this  account  there  is 
great  risk  in  applying  it  to  the  teeth  of  young  persons, 
or  to  any  teeth  that  are  highly  vascular ;  indeed,  it 
will,  in  some  cases,  destroy  the  vitality  of  very  dense 
teeth.  The  manner  in  which  it  passes  into  the  den- 
tine, is  not  very  definitely  understood.  It  is  very 
certain,  however,  that  in  more  highly  organized 
parts,  it  is  carried  through  by  the  circulation,  and 
also  may  be  taken  up  by  imbibition.  In  either  of 
these  ways  it  may  pass  into  the  dentine,  and  so  far  as 
concerns  the  results,  it  matters  not  in  which  way.  It 
is  enough  to  know  that  there  are  well  defined  cases 
of  its  specific  effect  on  the  constitution,  after  having 
been  applied  to  toothbone — demonstrating  that  it 
must  have  been  taken  up  by  the  circulation  ;  and 
also  cases  of  its  manifest  effect  on  the  periosteum  in 
a  short  time  after  having  been  applied  to  the  cavity 
of  a  tooth,  the  pulp  of  which  is  dead — thus  proving 
that  it  must  have  been  absorbed  by  imbibition. 

If  arsenic   is  ever  employed  in  the  treatment   of 
sensitive  dentine,  it  should  be  suffered  to  remain  in 


220  PATHOLOGICAL    CONDITIONS. 

the  cavity  but  a  short  time — from  one  to  three  hours 
— and  then  the  part  with  which  it  was  in  contact, 
should  be  very  thoroughly  excavated ;  and  in  de- 
ciding in  what  cases  it  is  proper  to  use  it,  there  is 
need  of  careful  discrimination  as  to  the  tooth's  struct- 
ure and  density;  for  injurious  results  have  some- 
times followed  its  application,  notwithstanding  the 
utmost  care  :  if  it  has  once  been  absorbed  by  the 
dentine,  antidotes  will  avail  nothing.  On  the  whole, 
therefore,  it  is  probably  better  to  refrain  from  its  use 
altogether  in  the  treatment  of  sensitive  dentine. 

Alkaline  caustics  have  been,  to  some  extent,  used 
for  the  treatment  of  this  affection.  A  preparation 
made  after  the  following  formula,  is  said  to  relieve 
some  cases  very  promptly  :  take  Canada  balsam  and 
slacked  lime,  and,  having  made  them  into  a  paste, 
fill  the  cavity  partially  full  with  it,  and  permit  it  to 
remain  until  the  object  is  accomplished. 

The  sensitiveness  of  dentine  may  be  obtunded  by 
thorough  friction  on  the  affected  part  with  a  smooth 
burnisher.  This  method,  however,  is  applicable  only 
to  those  cases  in  which  there  is  room  to  use  the  in- 
strument. On  the  surfaces  of  the  teeth,  where  there 
may  be  sensitiveness,  it  is  very  applicable  and  very 
efficient.  Simple  pressure,  without  friction,  it  is  sug- 
gested, will  accomplish  the  same  object;  though  press- 
ure and  friction  combined,  are  doubtless  more  effi- 
cient. 


CHAPTER  IX. 

EXPOSED     PULPS. 

Usually,  when  the  pulps  of  the  teeth  are  exposed, 
it  is  in  consequence  of  decay,  but  sometimes  of  a 
Gradual  wearing-clown  of  the  organs  in  mastication. 
When  the  pulp  of  a  tooth  is  found  exposed,  the 
course  of  remedy  to  be  pursued,  will  be  directed  by 
the  following  considerations  : — 

1st.  The  constitution  and  the  vital  energy  of  the 
system. 

2d.  The  condition  of  the  mouth  and  teeth. 

3d.  The  condition  of  the  pulp. 

4th.  The  size  of  the  orifice  at  which  it  is  exposed. 

5th.  Whether  the  exposure  is  of  recent,  or  of 
remote  origin. 

Gth.  If  in  a  tooth  of  more  than  one  fang. 

7th.  The  position  of  the  tooth  in  the  mouth,  and 
that  of  the  decayed  cavity  in  the  tooth. 

The  propriety  of  attempting  to  preserve  the  vital- 
ity of  the  pulp  after  exposure,  has  been  cpuestioned. 
Some  take  the  position  that  after  the  development 
and  formation  of  the  tooth,  the  pulp  is  no  longer  of 


222  EXPOSED    PULPS. 

any  use,  and  may,  without  damage,  be  dispensed 
with ;  while  others  maintain  that,  when  the  pulp  of 
a  tooth  is  destroyed,  the  tooth  is  no  longer  of  any 
value.  The  truth  is,  perhaps,  a  medium  between 
these  extremes.  The  pulp  of  the  tooth  is  valuable 
in  the  economy,  or  nature  would  dispense  with  it. 
Analogy  teaches  that  it  would  not  be  retained  longer 
than  it  could  subserve  some  beneficial  purpose.  But 
it  is  also  true,  that  a  tooth  may  be  valuable  for  a 
long  time  after  the  destruction  of  its  pulp,  notwith- 
standing it  is  in  a  less  perfect  condition ;  though  it  is 
always  desirable  perfectly  to  preserve  the  life  of  the 
tooth ;  for  the  crown  depends  on  the  pulp  for  its  vital- 
ity, and  living  dentine  opposes  more  resistance  to 
decay  than  dead;  besides,  a  dead  tooth  never  pre- 
sents the  bright,  lifelike  appearance  of  a  living  one. 
The  parts  about  a  dead  tooth,  too,  are  far  more  liable 
to  disease  than  those  about  a  living  one.  These  are 
only  a  few  of  the  prominent  arguments  for  retaining 
the  nerves  of  the  teeth. 

It  has  been  maintained  that  the  structure  of  the 
tooth-pulp  is  of  such  peculiar  character,  and  so  sus- 
ceptible of  diseased  action,  that  after  it  has  become 
affected,  though  but  slightly,  it  can  not  be  restored 
to  a  healthy  condition.  We  see  no  ground,  however, 
for  such  an  assumption,  except  it  be  in  the  imperfect 
treatment  which  this  organ  so  frequently  receives; 
for  the  fact  of  its  delicate  structure  does  not  neces- 


EXPOSED    PULPS.  223 

sarily  imply  an  impossibility  of  restoring  it  from 
disease.  The  pulp  of  the  tooth  is  endowed  with 
such  functions  as  ordinarily  render  living  tissue  sus- 
ceptible of  treatment  for  abnormal  conditions;  as 
circulation,  nutrition,  absorption,  and  a  distribution 
of  nerves.  The  success  attending  the  methods  of 
treating  exposed  pulp,  practised  by  the  dental  profes- 
sion during  the  last  few  years,  is  a  source  of  more 
encouragement  than  a  thousand  theories. 

Treatment  of  Exposed  Pulps. — In  cases  where  the 
conditions  are  favorable, — the  constitution  good,  the 
pulp  but  recently  exposed  at  a  small  orifice,  and  in  a 
healthy  condition,  treatment  may  be  instituted  with 
considerable  certainty  of  success.  If  there  is  no  in- 
flammation or  irritation,  therapeutic  treatment  is  not 
indicated ;  but  the  decay  should  be  removed  and  the 
cavity  formed  without  wounding  the  pulp,  if  possible; 
though  a  slight  wound  is  of  no  serious  consequence ; 
for  immediately  after  the  hemorrhage  ceases,  the 
operation  may  proceed  as  though  the  pulp  were 
intact.  There  have  been  suggested  various  methods 
for  protecting  the  pulp  in  cases  of  this  kind :  for- 
merly, the  capping  of  nerves  was  very  extensively 
practised ;  by  which  a  shield  was  thrown  over  the 
pulp,  so  as  to  prevent  the  filling  from  coming  in  con- 
tact with  it.  Various  materials  have  been  suggested 
for  caps;  but  gold  and  lead  have  been  chiefly  used 
for  the  purpose,  especially  when   the  object  was  to 


224  EXPOSED    PULPS. 

form  an  arch  over  the  point  of  exposure.  These 
caps  are  cut  out  of  thin  gold  plate,  or  thick  sheet 
lead,  of  the  proper  shape  and  size,  and  stamped  with 
a  convex  punch,  thus  receiving  such  a  concavity  as 
fits  them  for  covering  the  exposed  pulp  without 
touching  it.  A  little  groove,  of  depth  sufficient  to 
hold  the  cap  and  prevent  it  from  being  displaced  by 
the  introduction  of  the  filling,  may  be  made  in  the 
dentine  all  round  the  orifice  of  exposure.  The  cap  is 
then  to  be  adjusted  to  its  position  in  the  cavity,  hav- 
ing been  previously  touched  round  its  edge  with 
adhesive  wax,  and  the  filling  to  be  introduced  in  the 
usual  manner,  carefully,  so  as  not  to  displace  the 
cap ;  and  if  this  is  of  lead,  great  caution  is  to  be 
observed  in  condensing  the  filling  above  it,  since  it 
will  be  easily  compressed. 

The  therapeutic  influence  of  lead  on  exposed 
nerves  is  supposed  by  some  to  be  definite  and  de- 
cided ;  but,  though  lead  is  a  less  perfect  conductor  of 
heat,  and  in  this  respect  is  better  than  gold,  and 
though,  in  the  capacity  of  a  pulp-cap,  its  indestructi- 
bility is  probably  quite  sufficient,  yet,  if  no  change 
takes  place  in  it,  it  is  not  very  apparent  how  it  exer- 
cises any  therapeutic  action  on  the  pulp.  Experi- 
ence, however,  proves  that  the  success  is  quite  as 
good  in  the  use  of  lead  caps  as  in  that  of  gold ;  and 
the  former  are  much  more  easily  formed. 

There  is  an  other  method  of  shielding  an  exposed 


EXPOSED    PULPS.  225 

pulp,  which  is,  to  form  an  arch  over  it  by  the  filling. 
This  operation  is  performed  by  beginning  the  filling 
at  that  side  of  the  cavity  most  easily  approached, 
building  on  the  gold  from  the  bottom  to  the  orifice, 
up  almost  to  the  point  at  which  the  pulp  is  exposed, 
and  then  attaching  the  pieces  of  gold  to  the  prece- 
ding part,  without  permitting  them  to  come  in  contact 
with  the  pulp,  interposing  a  fine  burnished  point 
between  this  and  each  piece  as  it  is  introduced,  and 
thus  giving  a  smooth  surface  to  that  portion  of  the 
filling  next  the  nerve.  When,  by  this  process,  the 
filling  has  been  extended  beyond  the  point  of  expo- 
sure, it  may  be  dropped  down  on  the  body  of  the 
dentine,  and  finished  in  the  usual  manner.  This 
method  of  forming  a  protection  over  a  tooth-pulp, 
possesses  no  advantage  over  the  ordinary  cap ;  and 
being  much  more  difficult,  it  is  impracticable  in  any 
but  skillful  hands. 

This  practice  with  exposed  nerves,  however,  has, 
within  the  last  few  years,  been  almost  wholly  aban- 
doned, and  for  these  two  reasons  :  because  it  so  fre- 
quently failed  to  accomplish  the  object,  and  because 
a  better  method  of  treatment  has  been  discovered. 
It  was  found  that,  under  that  practice,  many  cases 
which  at  first  promised  well,  failed  to  preserve  the 
life  of  the  pulp ;  though  the  fatal  results  were  not 
always  immediate,  a  year  or  two,  and,  in  some  in- 
stances, a  much  longer  period,  intervening  between 


226  EXPOSED    PULPS. 

the  operation  and  the  death  of  the  tooth.  In  favor- 
able cases,  the  pulp,  even  after  exposure,  will,  if  pro- 
tected from  the  influence  of  foreign  substances,  throw 
out  a  bony  deposit,  and  even  close  up  an  orifice  of 
exposure,  thus  forming  for  itself  a  natural  shield.  It 
is  submitted  that  the  capping  operation  is  not  the 
best  protection  for  facilitating  this  process.  It  is 
probable  that,  in  some  cases,  the  space  between  the 
cap  and  the  pulp,  though  it  were  large,  would  be 
filled  with  coagulable  lymph ;  yet,  even  if  it  were 
thus  filled,  this  lymph  might  not  be  formed  into  bony 
tissue  ;  and  if  it  were  not,  it  could  not  fail  ultimately 
to  prove  injurious  to  the  pulp.  But  if  the  space 
should  not  be  filled  with  lymph,  the  difficulty  would 
be  equally  as  great,  since  the  pulp  would  protrude 
through  into  the  vacuum  beneath  the  cap,  and  neces- 
sarily become  diseased,  since  it  would  be  irritated  by 
its  contact  with,  and  its  pressure  against,  the  sharp 
edges  of  dentine  at  the  orifice  of  the  cavity  ;  and  it 
may  remain  thus  diseased  for  a  long  time,  or  die  at 
once.  Thus  it  is,  no  doubt,  that  the  great  majority 
of  failures  occur  under  this  kind  of  treatment.  In 
order  to  obviate  this  difficulty,  it  has  been  suggested 
that  the  space  under  the  cap  be  filled  with  some 
appropriate  substance,  as  a  thick  solution  of  gutta 
percha  and  chloroform,  or  a  small  pledget  of  cotton 
saturated  with  collodion. 

The    frequent   failures    which    occur   in    capping 


EXPOSED    PULPS.  227 

nerves,  have  incited  the  profession  to  seek  some  other 
method  of  treatment.  A  vacuum  above  the  nerve 
being  objectionable,  some  suitable  material  is  employed 
as  a  shield  for  this,  being  placed  on  the  orifice  of  ex- 
posure, in  contact  with  the  nerve  ;  and  the  filling  is 
then  introduced  without  any  pressure  upon  the  point 
of  exposure.  There  are  several  substances  that  have 
been  thus  employed,  the  chief  of  which  are  asbestos, 
oiled  silk,  collodion,  gutta  percha,  and  horn.  The 
material  for  this  purpose  should  be  a  nonconductor  of 
heat,  should  not  be  subject  to  decomposition  when  in 
contact  with  the  pulp,  and  should  present  a  smooth 
surface  and  be  easily  adapted.  In  shielding  a  nerve 
in  this  manner,  it  is  important  that  pressure  be  not 
made  upon  it;  and  there  is  not  much  liability  to  this, 
where  the  orifice  of  exposure  is  small ;  but,  where  it 
is  large,  much  care  is  required  in  the  introduction  and 
consolidation  of  the  plug.  The  opinion  has  been 
entertained  by  some,  that  the  pulp  of  a  tooth  will 
not  tolerate  any  foreign  substance  in  contact  with  it ; 
but  facts  refute  such  an  opinion.  By  this  kind  of 
protection  for  a  nerve,  secondary  dentine  is  more 
likely  to  be  developed. 

A  very  perfect  covering  for  an  exposed  pulp  may 
be  made  by  dropping  on  it  a  little  collodion  or  solu- 
tion of  gutta  percha,  and  then,  after  the  evaporation 
of  the  ether  or  chloroform,  filling  over  it.  This 
method  has  the  advantage  of  completely  filling  and 


228  EXPOSED    PULPS. 

occupying  the  space,  and  exactly  conforming  the  fill- 
ing to  the  part.  When  the  exposure  is  at  a  large 
orifice,  if  the  pulp  is  healthy,  and  the  constitution  of 
the  patient  good,  the  same  general  course  of  treat- 
ment may  be  adopted,  except  that  more  care  and 
skill  will  be  necessary  in  the  performance  of  an  opera- 
tion. Indeed,  it  is  difficult  to  make  a  good  operation 
in  cases  of  this  kind,  using  for  the  covering  only  a 
soft  or  a  very  flexible  material. 

A  method  of  operating,  that  is  probably  more  effi- 
cient than  any  other,  is,  to  prepare  the  cavity  as 
already  directed,  place  on  the  pulp  two  or  three  drops 
of  collodion  or  solution  of  gutta  percha,  letting  it 
partially  stiffen,  and  then  over  this  fit  a  gold  cap  as 
exactly  as  possible,  so  that  it  shall  rest  on  the  solid 
dentine  far  enough  from  the  orifice  of  exposure  to 
preclude  it  from  injurious  influence  on  the  pulp.  On 
this,  the  filling  is  introduced  as  usual,  care  being  had 
not  to  displace  the  cap,  which,  in  all  such  cases, 
should  have  a  seat  made  for  it,  adapted  at  the  time 
of  the  preparation  of  the  cavity. 

When  the  pulp  of  a  tooth  becomes,  by  exposure, 
inflamed  or  diseased,  some  more  special  treatment  is 
indicated,  and  usually  it  is  therapeutic.  In  every 
such  case,  the  treatment  will  contemplate  two  objects: 
the  preservation  of  the  pulp,  when  the  circumstances 
will  warrant;  and  when  they  will  not,  then  its  de- 
struction.    The  former  of  course  is  always  to  be  pre- 


EXPOSED    PULPS.  229 

ferred,  where  practicable.  Some  of  our  best  operators 
very  strongly  denounce  that  wholesale  destruction  of 
the  pulps  of  teeth,  practised  by  many;  while  some 
dentists  never  attempt  to  restore  them  to  health  at 
all,  however  slightly  diseased.  This,  as  elsewhere 
intimated,  is  erroneous  practice  ;  for  there  is  no  obvi- 
ous reason  why  the  pulp  of  a  tooth  may  not  be  re- 
stored from  disease  to  health  as  readily  as  other  parts, 
endowed,  as  it  is,  with  circulation,  nutrition,  absorp- 
tion, and  the  distribution  of  nerves.  The  particular 
kind  of  treatment  required  in  any  given  case,  how- 
ever, will  be  controlled  by  various  circumstances; 
such  as  the  nature  and  extent  of  the  disease  ;  whether 
it  is  of  chronic  or  acute  type  ;  and  when  the  irrita- 
tion, or  inflammation,  is  but  slight,  and  is  kept  up 
solely  by  the  contact  of  irritating  substances,  restora- 
tion of  the  pulp  may  be  effected  by  a  removal  of  these 
irritating  causes,  and  a  protection  of  the  pulp  against 
their  further  influence :  in  such  case,  nature,  unaided, 
effects  the  restoration.  In  default  of  a  vigorous  con- 
stitution, the  pulp,  though  but  slightly  affected,  will 
require  topical  therapeutic  treatment;  and  meanwhile 
general  treatment  may  be  employed  to  give  increased 
tone  to  the  system.  In  the  local  treatment,  neutral- 
izing agents  should  be  applied  first,  and  afterwards 
such  as  will  counteract  and  reduce  inflammation, 
especially  if  this  is  in  an  active  state.  But  if  the 
pulp  is  in  a  morbid  condition,  with  retarded  circula- 


230  EXPOSED    PULPS. 

tion,  and  a  tendency  to  enlargement,  very  active  and 
stimulating  applications  will  be  indicated,  and  in 
some  cases  escharotics,  such  as  nitrate  of  silver  and 
chlorid  of  zinc,  the  latter  especially  where  there  is  a 
tendency  to  prurient  enlargement  of  the  pulp.  Four 
therapeutic  principles,  namely,  astringents,  tonics, 
stimulants,  and  escharotics,  are  mainly  to  be  relied 
upon  in  the  topical  treatment  of  exposed  pulp ;  but 
a  detailed  account  of  the  nature,  influence  and  effects 
of  all  the  individual  agents  embodying  these  prin- 
ciples, and  of  the  respective  methods  of  applying 
them,  belongs  rather  to  dental  therapeutics. 

The  length  of  time  requisite  for  the  treatment  of 
exposed  pulp,  will  vary  with  different  cases.  In  the 
case  of  a  recent  acute  inflammation,  the  process  of 
restoration  may  be  completed  in  two  or  three  days ; 
while,  in  other  cases,  where  the  difficulty  is  of  long 
standing  and  of  a  more  complex  character,  it  will  re- 
quire from  a  week  to  two  months.  Leeching  and 
counterirritation  of  the  gums  are  sometimes  resorted 
to  in  this  treatment ;  but  it  is  rare  that  any  definite 
beneficial  result  ensues.  Depletion  of  the  pulp  itself 
may  often  be  practised  with  decided  success  :  and  it 
may  be  accomplished  either  by  puncturing  the  pulp 
with  a  fine-pointed  instrument,  or  by  excising  a  small 
portion  of  it  at  the  orifice  of  exposure  with  a  very 
sharp  one,  in  either  case  avoiding  any  laceration  of 
the  pulp.     By  this  means  the  distended  vessels  are 


EXPOSED    PULPS.  231 

relieved  ;  and  in  many  cases,  where  the  difficulty  is 
but  slight,  immediately  after  such  relief  by  punctur- 
ing, so  soon  as  the  hemorrhage  has  ceased,  the  tooth 
may  be  filled.  But  if  the  depletion  is  by  excision, 
time  must  be  allowed — ordinarily  from  three  to  ten 
days. 

The  formation  of  secondary  dentine,  by  which  the 
orifice  of  exposure  is  closed  up,  has  already  been  re- 
ferred to ;  and  it  has  been  suggested  that  treatment 
to  facilitate  this  process  may  be  instituted.  With  a 
view  to  this,  temporary  fillings  are  sometimes  intro- 
duced; and  irritation  of  the  pulp  by  frequent  slight 
friction,  has  been  adopted ;  but  the  success  attending 
this  treatment  is  not  very  manifest.  If  a  shield  of 
secondary  dentine  is  desirable  before  permanent  fill- 
ing, the  best  method  of  securing  it,  is,  after  seeing 
that  the  general  recuperative  power  is  in  the  best 
condition,  to  place  in  the  cavity  a  temporary  filling, 
of  such  material  and  in  such  manner  as  shall  be  least 
offensive  to  the  pulp,  and  then  leave  nature  to  accom- 
plish the  work.  In  many  cases,  especially  in  young 
persons,  this  process  would  be  facilitated  by  an  ad- 
ministration of  bone  phosphate.  The  pulps  of  the 
teeth  of  the  young  are  more  difficult  to  treat  success- 
fully than  those  of  the  more  advanced  in  life. 

Destruction  of  the  Palp. — There  are  cases  in  which 
an  attempt  to  restore  the  pulp,  even  when  recently 
and  but  slightly  diseased,  would  prove  unavailing : 


232  EXPOSED    PULPS. 

so  feeble  is  the  vitality  that  it  is  destroyed  at  almost 
the  first  touch.  Two  cases  in  apparently  the  same 
condition  pathologically,  but  in  different  constitu- 
tions, will,  under  the  same  treatment,  exhibit  very 
different  results.  A  pulp  that  is  highly  diseased,  is 
but  seldom,  if  ever,  under  any  circumstances,  sus- 
ceptible of  restoration;  and  in  such  case,  of  course, 
destruction  is  indicated.  This  was  formerly  supposed 
to  be  an  impracticable  operation,  for  two  reasons : 
first,  because  it  was  very  difficult  and  painful ;  and 
second,  because  of  the  consequences  likely  to  ensue. 
Then,  the  operation  was  attempted  only  on  teeth  of 
one  fang,  and  those  of  cylindrical  form ;  but  now,  it 
is  performed  successfully  on  all  classes  of  teeth. 
When  destruction  of  the  pulp  is  decided  upon,  such 
means  should  be  employed  as  will  effect  the  object 
promptly  and  thoroughly.  Every  thing  should  be 
entirely  removed  from  the  pulp-chamber  and  the 
canal  of  the  fang ;  for  any  remaining  portion  is  liable 
to  inflammation  and  suppuration ;  and  alveolar  ab- 
scess, too,  frequently  ensues. 

There  are  two  methods  of  destroying  the  pulp  :  the 
one,  by  an  operation ;  the  other,  by  a  therapeutic 
application.  The  choice  of  these  methods  will  be 
governed  by  circumstances;  such  as  the  temperament 
of  the  patient,  the  condition  of  the  tooth  and  parts 
about  it,  the  class  of  the  tooth  to  be  operated  upon. 
For  patients  of  a  nervous,  irritable  temperament,  to 


EXPOSED    PULPS.  233 

« 

whom  a  removal  of  the  pulp  by  an  operation  would 
occasion  great  pain  and  a  severe  shock,  it  would  be 
better  to  apply  some  agent  to  destroy  the  vitality 
of  the  pulp,  and  then  remove  it ;  but,  on  the  con- 
trary, where  there  is  vigor,  a  capacity  of  endurance, 
it  is  preferable  to  remove  the  pulp  at  once  by  an 
operation.  To  accomplish  this,  there  are  two  or 
three  methods  of  manipulation.  In  the  first  place, 
however,  by  whatever  method  it  is  removed,  it 
should  be  fully  exposed ;  the  orifice  of  exposure 
should  be  as  large  as  the  pulp-chamber,  and  the  en- 
trance as  nearly  as  possible  on  a  line  with  the  tooth's 
axis;  hence  it  will  be  necessary  in  many  cases  to 
make  an  opening  into  the  pulp-chamber  at  a  point 
different  from  that  of  the  opening  caused  by  the 
decay.  For  instance,  in  the  incisor  teeth,  when  the 
decayed  cavity  is  small  on  the  side  near  the  margin 
of  the  gum,  penetrating  to  the  nerve-chamber,  and 
exposing  the  pulp,  the  entrance  through  this  opening 
into  the  canal  will  be  almost  at  right  angles  with  it ; 
and  in  such  case  it  would  be  impossible,  through  this 
opening,  to  manipulate  freely  in  the  fang ;  and  it 
would  be  necessary  to  make  an  opening  with  a  drill 
through  the  palatal  portion  of  the  tooth  directly  into 
the  canal ;  which  opening  should  be  large  enough 
readily  to  allow  of  a  removal  of  the  pulp  through  it, 
and  of  an  unimpeded  performance  of  all  the  subse- 
quent operation  on  the  canal  of  the  fang. 


234  EXPOSED    PULPS. 

After  the  pulp  has  been  thus  exposed,  the  instru- 
ment should  be  selected  for  its  removal.  There  are 
different  forms  of  instruments  for  this  purpose.  Some 
operators  employ  the  untempered,  four-sided,  barbed 
broach,  thrusting  it  up  into  the  canal  as  far  as  pos- 
sible, then  twirling  it  two  or  three  times  around,  and 
thus  wrapping  the  nerve  round  the  instrument;  when 
both  are  drawn  away  together.  This  method  always 
occasions  considerable  pain.  Others  employ  simply 
the  three-  or  four-sided  broach,  thrusting  it  through 
the  pulp  all  the  way  up  the  canal,  and  thus  lacera- 
ting it  and  breaking  up  its  structure,  so  that  it  may 
afterward  be  removed  without  much  pain.  An  other 
very  awkward  and  bungling  method  is,  to  force  up 
into  the  canal  a  piece  of  wood  adapted  to  the  size  of 
the  space,  and  thus  drive  the  pulp  before  it  all  the 
way.  Of  all  the  methods  of  destroying  the  pulp,  this 
is  the  most  objectionable,  and  should  never  be  em- 
ployed. An  other  method,  and  the  one  which  seems 
preferable  to  all  others,  is  as  follows :  take  a  very 
fine  untempered  steel  wire,  round  and  smooth,  not 
larger  than  34  to  36  of  Stub's  gaugeplate  ;  flatten 
the  extreme  point,  and  turn  it  to  an  angle  of  from 
thirty  to  forty  degrees;  place  the  edge  of  this  against 
one  wall  of  the  canal  at  the  point  of  exposure  of  the 
pulp;  press  it  steadily  up  the  canal,  with  its  edge 
bearing  against  the  wall,  as  far  as  it  will  go,  and  then 
twirl  it  suddenly  round  :  thus  an  excision  is  effected 


EXPOSED    PULPS.  235 

near  the  point  of  the  fang,  when  the  pulp  with  the 
instrument  may  be  drawn  away  together;  or,  if  not 
thus  drawn,  it  may  be  caught  with  some  fine  point, 
and  removed  without  pain.  This  manner  of  intro- 
ducing the  instrument,  too,  causes  less  pain  than 
either  of  the  others ;  for  there  are  no  sharp  edges  or 
points  presented  in  passing  the  instrument  up  the 
canal,  to  cut  or  lacerate  the  pulp.  In  the  removal  of 
the  pulp  from  the  teeth  of  young  persons,  care  should 
be  taken  lest  the  instrument  pass  entirely  through 
the  foramen,  at  the  apex  of  the  fang ;  but  with 
adults,  there  is  little  or  no  danger  of  such  an  accident. 
The  directions  given  here  would  be  quite  sufficient, 
if  closely  followed,  for  the  removal  of  the  pulps  of 
the  six  anterior  superior  teeth.  In  order  to  the  re- 
moval of  the  pulp  from  the  bicuspids,  the  entrance 
can  ordinarily  be  effected  through  the  decayed  cavity. 
Usually,  there  is  some  lateral  compression  of  the 
fangs  of  these  teeth;  and  the  canal  through  the  fang- 
partakes  of  the  formation,  so  that  it  represents  a 
mere  fissure  expanded  a  little  on  each  side  of  the 
center.  It  is  often  difficult,  and  requires  very  deli- 
cate manipulation,  to  remove  all  the  pulp  from  these 
fissures  :  a  very  fine  instrument  may  be  pressed  down 
each  side,  and  yet  a  portion  of  the  pulp  remain  in 
the  center.  This  difficulty  is  most  fully  presented  in 
those  cases  in  which  there  has  been  an  apparent, 
though  abortive,  effort  of  nature  to  produce  two  fangs. 


236  EXPOSED    PULPS. 

The  removal  of  the  pulp  of  the  molar  teeth  is  a 
more  extensive  and  complicated  operation.  The 
pulp  to  be  operated  upon  should  be  fully  exposed, 
the  orifice  of  exposure  being  made  as  nearly  as  pos- 
sible of  the  size  of  the  pulp-chamber ;  and  the  instru- 
ment to  be  used,  should  be  such  as  last  described, 
except  that  it  should  be  much  larger,  and  is  to  be 
introduced,  in  the  same  manner,  to  the  bottom  of  the 
pulp-chamber,  and  rotated  suddenly,  so  as  to  cut  off 
the  ramifications  of  the  pulp  into  the  fangs,  thus  at 
one  sweep  dislodging  the  entire  body  of  it  without 
laceration.  The  practice  of  plunging  a  large  barbed 
or  cutting  instrument  into  the  pulp  of  a  molar  tooth, 
is  barbarous  in  the  extreme.  The  branches  of  the 
pulp  in  the  fangs  should  be  removed  in  the  manner 
already  directed  for  the  removal  of  the  pulps  from 
teeth  of  single  fangs.  The  palatal  fang  is  very  easily 
operated  upon ;  but,  as  to  the  buccal  fang,  there  is 
frequently  encountered  the  same  difficulty  referred  to 
in  speaking  of  the  bicuspids.  Commonly,  when  a 
pulp  is  removed  in  this  manner,  the  wound  of  exci- 
sion heals  by  first  intention,  and  there  is  formed  a 
permanent  cicatrice. 

Actual  Cautery. — Formerly,  for  destroying  tooth- 
pulp,  the  actual  cautery  was  employed  to  a  consider- 
able extent,  and  was  at  one  time  a  favorite  method 
with  French  dentists.  This  consists  in  heating  a 
wire  of  proper  size  to  a  white  heat,  and  thrusting  it 


EXPOSED    PULPS.  237 

up  the  canal  of  the  fang  to  the  apex,  the  object  being 
to  destroy  the  pulp  the  instant  the  wire  comes  in 
contact  with  it.  The  operation  requires  much  skill, 
and  is  attended  with  many  difficulties.  It  is  fraught 
with  terror  to  the  patient ;  if  the  temperature  of  the 
wire  is  not  at  the  white  heat  at  the  time  of  its  inser- 
tion, the  pain  of  the  operation  is  most  intense ;  it  is 
liable  to  leave  the  parts  in  such  a  condition  as  often 
to  induce  inflammation  and  suppuration,  which  may 
involve  the  investing  membrane  and  the  surrounding 
parts.  Besides,  by  this  method,  the  object  is,  at 
best,  no  more  successfully  attained  than  by  others. 

Potential  Cautery. — This  term  is  applied  to  those 
therapeutic  agents  which  destroy  vital  tissue  by  estab- 
lishing a  condition  incompatible  with  vitality.  Many 
preparations  have  been  employed  as  topical  applica- 
tions to  destroy  the  pulps  of  teeth,  but  only  two  or 
three  to  any  considerable  extent.  A  consideration 
of  the  nature  and  specific  action  of  these  agents  may 
not  here  be  out  of  place ;  and,  first,  of 

Arsenious  Acid. — This  has  been  more  used,  topi- 
cally, for  the  destruction  of  tooth-pulp,  than  all  the 
other  applications.  The  first  account  we  have  of  its 
use  for  this  purpose,  dates  back  to  183G,  when  it  was 
applied  by  Dr.  Spooner,  though  others  claim  to  have 
employed  it  at  about  the  same  time.  The  specific 
action  of  arsenious  acid  on  vital  tissue  is  not  well 
understood.     It  is  supposed  by  some  that  it  forms  a 


238  EXPOSED    PULPS. 

compound  with  some  element  of  the  tissue,  and  in 
this  way  destroys  the  vitality. 

Any  such  combination,  however,  has  hitherto  es- 
caped detection ;  and  it  is  certain  that  if  a  compound 
is  formed,  it  is  not  fixed  or  permanent  in  its  char- 
acter, since  the  arsenic  will  be  carried  to  different 
parts  of  the  system,  and  its  specific  influence  mani- 
fested wherever  it  goes;  which  could  not  be  the  case 
if  it  formed  a  fixed  compound.  The  more  probable 
theory  is,  that  it  destroys  vitality  by  its  influence  on 
nerve  tissue.  Animal  tissue  takes  it  up  hy  imbibi- 
tion ;  and  it  is  also  absorbed  by  the  circulation,  and 
conveyed  by  it,  as  already  suggested,  throughout  the 
system.  Frequently,  however,  it  is  applied  to  living 
tissue  under  conditions  that  prevent  such  absorption. 
It  is  often  employed  in  the  treatment  of  carcinoma. 
In  the  application  of  arsenious  acid  to  the  pulps  of 
teeth,  for  their  destruction,  several  circumstances  are 
to  be  considered ;  such  as  the  age  of  the  patient,  the 
constitutional  tendency,  the  vascularity  of  the  den- 
tine. Where  the  vascularity  is  great,  the  utmost 
caution  is  required.  The  indiscriminate  use  of  this 
agent  in  the  teeth  of  the  young,  is  attended  with 
great  risk.  Some  constitutions  are  peculiarly  sus- 
ceptible of  its  influence,  experiencing  its  effects  even 
in  remote  parts  of  the  system,  after  its  application 
only  to  the  pulp  of  a  tooth.  It  is  absorbed  more 
readily  in  solution  than  in  solid.     It  is  very  soluble 


EXPOSED    PULPS.  239 

in  creosotes  and  all  the  oils  of  that  nature,  and  some- 
what soluble  in  alcohol  and  water.  In  many  cases, 
when  it  is  applied  to  the  pulp  of  a  tooth,  more  or  less 
disturbance  of  the  periosteum  is  exhibited  a  short 
time  after — in  some  instances  in  a  few  hours,  and  in 
others  after  several  days ;  thus  giving  evidence  that 
it  has,  by  some  means,  come  in  contact  with  the  pe- 
riosteum. Its  influence  on  this  will  often  be  mani- 
fested under  percussion,  in  advance  of  any  other 
symptoms. 

Appliccdion. — There  are  two  or  three  methods  of 
applying  arsenious  acid  for  the  destruction  of  the 
pulps  of  teeth.  The  ordinary  arsenic  of  commerce  is 
used.  It  was  formerly  employed  very  extensively  in 
connection  with  sulphate  of  morphia,  mixed  in  equal 
parts,  and  applied  to  the  pulp  with  a  small  pledget  of 
cotton,  moistened  with  creosote  or  any  other  essential 
oil,  the  former  being  most  frequently  used.  Alcohol, 
ether,  or  water  may  be  employed  in  stead  of  creosote, 
and  in  some  respects  and  in  some  cases  would  be 
preferable.  The  pledget  of  cotton,  thus  prepared,  is 
introduced  into  the  decayed  cavity,  with  the  prepara- 
tion in  contact  with  the  exposed  pulp.  An  other 
pledget  of  cotton,  saturated  with  a  thick  solution  of 
gum  sandarac  and  alcohol,  or  gutta  percha  and  chlo- 
roform, is  placed  over  this  in  the  cavity,  to  prevent 
the  escape  of  the  preparation,  or  the  entrance  of 
moisture  or  foreign  substances :  any  preparation  may 


240  EXPOSED    PULPS. 

be  used,  that  will  accomplish  these  objects.  In  the 
application  of  the  pledget,  care  must  be  exercised  lest 
too  much  pressure  be  made  on  the  pulp,  and  pain  be 
thus  produced.  In  order  to  prevent  this  pressure, 
an  other  method  has  been  adopted,  which  consists  in 
forming  a  cap  of  lead,  placing  in  it  the  arsenic,  in  the 
dry  state  or  with  some  suitable  solvent,  and  then  fit- 
ting it  over  the  exposed  pulp,  and  retaining  it  there 
with  a  pledget  of  cotton,  as  above,  or  with  Hill's 
Stopping,  gutta  percha,  or  adhesive  wax.  Thus  the 
preparation  comes  gently  into  contact  with  the  pulp, 
and  prevents  any  pressure  on  it.  The  morphine  is 
used  for  the  purpose  of  diminishing  the  pain  which 
frequently  results  from  the  application  of  arsenic; 
but  its  influence  for  such  a  purpose  is  predicated 
more  on  theory  than  on  practice ;  for  facts  prove 
that,  applied  to  living  tissue,  it  produces  pain  rather 
than  allays  it.  Therefore  the  more  observing  and 
better  class  of  practitioners  have  discarded  it. 

Other  substances  have  been  mixed  with  arsenic, 
for  the  purpose  of  mitigating  or  altogther  relieving 
the  deleterious  consequences  so  liable  to  follow  its 
administration ;  as,  for  instance,  pulverized  charcoal, 
which  combined  with  it  in  equal  parts  by  weight, 
makes  a  favorite  preparation  with  good  practitioners, 
by  some  of  whom  it  is  claimed  that  the  charcoal 
counteracts  the  specific  effect  of  the  arsenic  on  parts 
other  than  those  for  which    it  is  directly  designed. 


EXPOSED   PULPS.  241 

But  this  theory,  in  the  light  of  any  elucidation  yet 
given,  is  very  vague.  The  claim  can  not  be,  that 
charcoal  is  an  antidote  to  arsenic,  since  facts  refute 
it ;  for  if  it  were  such  antidote,  the  arsenic  of  the 
preparation,  when  applied  to  the  pulp  of  a  tooth, 
would  fail  of  its  effect,  because  the  charcoal,  being 
also  in  contact  with  the  pulp,  would  there,  if  ever, 
counteract  the  poison.  But  this  it  does  not  do;  for 
the  pulp  is  destroyed  about  as  readity  by  this  prepa- 
ration as  by  arsenic  alone.  And  if,  when  the  arsenic 
and  charcoal  are  thus  together,  no  counteracting 
influence  of  the  latter  is  manifest,  much  less  will 
there  be  any  when  the  arsenic,  escaped  from  the 
charcoal,  runs  riot  through  the  organic  tissues, 
whither  the  latter  can  not  follow.  The  only  prob- 
able advantage,  then,  of  this  preparation,  is,  that  the 
arsenic  is  not  taken  up  from  it  by  the  tissues  so 
rapidly,  as  when  that  is  applied  alone  or  with  any 
thing  that  is  soluble  with  it;  for,  when  thus  applied, 
tin1  whole  is  very  soon  dissolved,  and  taken  up  by 
the  pulp  and  dentine.  But,  when  combined  with 
charcoal  or  the  like,  little  more  of  the .  arsenic  is 
absorbed  than  that  which  comes  in  contact  with  the 
pulp.  Hence  the  conclusion,  that  the  influence  of 
the  charcoal  is  mechanical,  and  not  therapeutic. 

This  preparation  is  better  applied  perfectly  dry, 
beneath  a  lead  cap,  which  should  completely  close 
the  cavity.     Any  other  material  that  would  mix  as 

Q 


242  EXPOSED    PULPS. 

readily  with  the  arsenic,  without  being  soluble,  and 
that  would  not  induce  irritation  when  in  contact  with 
the  pulp,  would  be  quite  as  good  for  this  purpose  as 
charcoal.  Irritating  gasses  generated  in  a  tightly 
closed  cavity,  may  be  absorbed  by  charcoal. 

Cobalt,  in  which  the  active  principle  is  arsenic,  has 
been  extensively  used  for  destroying  nerves;  but  it  is 
in  no  respect  superior,  and  in  some  respects  it  is  prob- 
ably inferior,  to  the  preparation  of  charcoal  and 
arsenic :  it  is  applied  in  the  same  manner. 

The  length  of  time  the  preparation  should  remain 
in  the  tooth,  will  be  determined  from  the  condition 
of  the  pulp  when  it  is  applied,  the  age  of  the  patient, 
the  vascularity  of  the  dentine,  the  susceptibility  of 
the  patient  to  the  influence  of  arsenic,  and  the  like 
circumstances.  It  will  usually  be  from  three  to 
twentyfour  hours.  In  some  cases,  a  very  small  par- 
ticle will  thoroughly  accomplish  the  work ;  while  in 
others,  a  much  larger  quantity  may  remain  in  con- 
tact with  the  pulp  even  for  a  much  longer  time, 
without  producing  more  than  a  superficial  result. 
And  cases  occasionally  occur,  in  which  it  seems 
almost  impossible  to  destroy  the  vitality  of  a  pulp 
with  arsenic.  A  case  is  on  record,  in  which  the  pulp 
was  first  fairly  exposed  in  a  superior  bicuspid  tooth, 
the  health  and  constitution  being  good,  and  the  tem- 
perament sanguine-lymphatic;  and  arsenic  with  mor- 
phine was  applied  to  it,  directly,  five  times  within 


EXPOSED    PULPS.  243 

ten  clays,  without  producing  any  apparent  effect; 
then  an  application  of  creosote  and  tannin  was  made 
three  or  four  times,  during  as  many  days;  afterward 
the  tooth  was  temporarily  filled  with  gutta  percha; 
and  finally,  in  ten  or  twelve  days,  this  filling  being 
removed,  the  pulp  appeared  in  a  state  of  perfect  pres- 
ervation and  health,  with  all  the  indications  of  un- 
diminished vitality.  Over  the  exposed  point  there 
was  placed  a  nonconductor,  and  upon  it  a  filling  of 
gold ;  and  one  year  after,  the  tooth  presented  the 
appearance  of  perfect  life  and  health,  having  given 
the  patient  no  annoyance  during  the  whole  period. 
Several  similar  cases  might  be  cited,  if  it  were  neces- 
sary. 

Hence  it  is  quite  obvious  that  there  is  a  great  di- 
versity of  susceptibility  to  the  influence  of  arsenic, 
and  that  the  study  of  these  idiosyncrasies  is  both  in- 
teresting and  valuable.  The  recurrence  of  injurious 
consequences  from  the  use  of  arsenic,  has  induced 
many  operators  to  abandon  it  altogether.  But  these 
injurious  results  perhaps  occur  always  either  through 
maladministration,  or  from  a  peculiar  susceptibility 
to  the  influence  of  the  drug ;  and  a  superior  skill  and 
a  more  accurate  diagnosis  would  avoid  them  entirely. 
After  the  desired  result  with  arsenic,  it  has  been 
thought  that  antidotes  might  be  made  available. 
The  hydrated  sesquioxyd  of  iron  is  one  of  the  best 
antidotes  to  arsenic,  and  has  been  used  in  the  teeth 


244  EXPOSED    PULPS. 

to  counteract  its  injurious  effects;  but  it  is  of  no 
avail  here ;  the  arsenic  has  the  start  of  it,  and,  in- 
deed, would  outstrip  it,  with  an  equal  start. 

From  the  foregoing  in  regard  to  arsenic  as  an  ap- 
plication for  destroying  the  nerves  of  teeth,  the  fol- 
lowing conclusions  are  justly  deducible  :  it  is,  in 
general,  very  efficient;  it  is  a  heroic  agent;  it  should, 
in  all  cases,  be  used  with  great  caution ;  in  some 
cases  it  is  entirely  inadmissible;  a  free  administration 
of  it  is  liable  to  be  succeeded  by  bad  consequences ; 
and  skill,  rather  than  counteracting  agents,  is  to  be 
relied  upon  in  its  application. 

Filling  Palp  Cavities  and  Canals. — After  the  pulp 
of  a  tooth  has  been  destroyed,  whether  by  an  opera- 
tion or  by  therapeutic  treatment,  the  part  at  the 
point  of  its  detachment  should,  in  almost  all  cases, 
before  the  filling  is  introduced,  be  rendered  sound;  if 
possible,  a  permanent  cicatrice  should  have  formed. 
In  cases,  however,  of  good  constitution  and  strong 
recuperative  power,  where  a  nerve  has  been  removed 
by  an  operation,  the  fang  may  be  filled  as  soon  as  the 
hemorrhage  has  ceased ;  but  such  cases  rarely  occur. 
Generally,  the  part  will  require  treatment;  and  the 
character  and  duration  of  this  will  be  determined  by 
the  circumstances — as,  the  vital  energy  of  the  system, 
and  the  method  employed  for  the  pulp's  destruction. 
When  this  has  been  effected  by  an  operation,  the 
part   of  detachment  is  restored   to  soundness  much 


EXPOSED    PULPS.  245 

more  readily  than  when  by  an  application  of  arsenious 
acid,  and  less  topical  treatment  will  ordinarily  be  re- 
quired ;  indeed,  in  many  such  cases  there  will  be 
nothing  else  necessary,  than  to  keep  the  canal  well 
cleansed,  so  as  to  obviate  any  irritation  that  other- 
wise might  be  induced  by  the  offensive  gasses  or  fluids 
of  decomposition.  But  it  is  generally  best  to  employ 
some  deodorizing  agent,  such  as  chlorid  of  sodium,  in 
these  cases.  When  the  pulp  has  been  destroyed  by 
arsenious  acid,  more  energetic  treatment  is  usually 
demanded ;  for  then  there  is  always  a  greater  or  less 
disposition  to  slough  or  discharge  through  the  tooth ; 
which  must  of  course  be  entirely  abated,  before  the  ope- 
ration of  filling  is  at  all  admissible.  In  the  treatment 
of  this  condition,  the  canal  should  be  kept  perfectly 
clean  by  frequent  syringing;  floss  silk,  moistened  with 
some  suitable  liquid,  such  as  a  solution  of  nitrate  of 
silver,  or  creosote  and  tannin,  should  be  introduced 
up  to  the  inmost  part  of  the  cavity,  and  should  be 
changed  every  twentyfour  hours,  the  cavity  being 
thoroughly  washed  each  time.  It  will  be  necessary, 
in  many  cases,  to  continue  this  treatment  for  several 
days.  In  order  to  determine  whether  the  condition 
is  such  as  to  admit  of  the  filling,  the  floss  silk  should 
be  removed  after  a  sufficient  time  is  supposed  to  have 
elapsed,  the  cavity  thoroughly  cleansed  and  dried, 
and  a  portion  of  dry  floss  or  cotton  introduced  loosely 
into  the  canal.     Then  close   up  the  decayed  cavity 


246  EXPOSED    PULPS. 

with  adhesive  wax,  gutta  perch  a,  or  some  other  sub- 
stance that  will  effectually  exclude  the  moisture;  let 
it  remain  thus  from  twelve  to  twentyfour  hours;  then 
open  the  cavity,  and  withdraw  the  silk  or  cotton,  and 
if  this  is  found  free  from  moisture  and  odor,  the  tooth 
is  ready  to  be  filled. 

The  treatment  just  described  will  be  sufficient  for 
all  cases  in  which  the  pulp  has  been  destroyed  by  the 
operator.  But  teeth  whose  pulps  are  already  dead, 
would  seem  to  be  less  difficult  of  treatment  and  fill- 
ing ;  yet  they  are  not  so ; — indeed,  the  therapeutic 
treatment  of  these  is  usually  more  protracted,  and 
their  diseased  condition  less  easily  controlled ;  and 
this  because  of  the  fact  that  the  decaying  pulp,  re- 
maining in  the  canal,  becomes  very  offensive  to  the 
living  parts  adjacent,  in  which  it  induces  a  chronic 
diseased  condition,  frequently  involving  the  dentine 
along  the  walls  of  the  canal  in  decomposition. 

A  classification  of  these  teeth,  based  on  their  con- 
ditions, might  be  somewhat  auxiliary  to  a  further 
examination  of  this  subject;  and  the  following  will 
probably  embrace  them  all : — 

1st.  Those  whose  pulps  are  dead,  but  their  remain- 
ing parts  alive  and  healthy. 

2d.  Those  predisposed  to  disease. 

3d.  Those  already  diseased,  either  discharging 
acrid  matter  through  the  fang,  or  exhibiting  inflam- 
mation of  the  periosteum. 


EXPOSED    PULPS.  247 

4th.  Those  having  alveolar  abscess. 

Sound  or  slightly  decayed  teeth  are  sometimes 
found  with  dead  pulps.  This  condition  may  be  pro- 
duced in  various  ways  :  by  blows,  or  by  any  force 
that  will  partially  loosen  the  tooth ;  by  undue  press- 
ure in  filling ;  by  excessive  sensitiveness  .  of  the 
dentine,  even  where  the  decay  is  not  extensive ;  and, 
sometimes,  by  a  filling  of  the  tooth  when  it  is  in  an 
unfit  state  for  the  operation.  Ordinarily,  in  cases  in 
which  the  pulp  is  dead  before  its  exposure,  and  there 
is  no  abscess  from  the  fling  or  periosteum,  the  nerve- 
chamber  may  be  opened,  and  the  remains  of  the  pulp 
removed.  The  canal  should  then  be  cleansed  out, 
and  floss  silk  saturated  with  chlorid  of  sodium,  in- 
troduced and  permitted  to  remain  from  one  to  six 
hours;  when  it  should  be  withdrawn,  the  pulp-cavity 
and  the  canal  again  thoroughly  cleansed,  and,  there 
being  no  discharge  of  pus  through  the  fang,  it  may 
then  be  filled.  The  fact  that  the  dead  pulp  is  inclosed 
in  its  chamber  without  producing  irritation,  is  evi- 
dence that  there  is  no  secretion  of  pus.  Occasion- 
ally, where  the  pulp  has  died  from  exposure, 
the  living  part  immediately  adjacent  will  present  a 
healthy  condition,  and  there  will  be  no  discharge ; 
such  cases  should  be  treated  in  the  manner  just  de- 
scribed. In  operating  on  teeth  already  dead,  more 
delicate  manipulation  is  requisite  to  prevent  irrita- 
tion, than  on  those  in  which  the  pulp  is  destroyed  by 


248  EXPOSED    PULPS. 

the  operator.  In  very  many  cases  of  dead  teeth, 
where  there  is  not  a  state  of  actual  disease,  there  is 
a  strong  predisposition  to  it ;  and  in  these  cases,  the 
preparation  of  a  cavity,  or  the  introducing  and  con- 
densing of  a  filling,  will  produce  inflammation  of  the 
periosteum.  When  such  a  condition  is  recognized, 
several  sittings  may  be  required  to  complete  the  ope- 
ration. But  it  is  not  always  easy  to  recognize;  yet, 
whenever  it  is  suspected,  it  is  well  to  press  the  inves- 
tigation, which  may  be  guided  by  the  following  rules : 
ascertain  whether  the  tooth  experiences  a  different 
sensation  or  any  pain,  under  percussion  in  any  direc- 
tion ;  whether  periostitis  has  ever  existed  in  that  or 
in  a  contiguous  tooth ;  whether  the  parts  adjacent  to 
the  tooth  are  in  a  healthy  state ;  whether  there  is  a 
general  inflammatory  diathesis,  or  an  enfeebled  con- 
dition. These  are  the  prominent  points  in  an  exami- 
nation of  this  kind. 

Where  this  predisposition  exists,  it  may  be  coun- 
teracted by  general  or  local  treatment,  according  as 
it  depends  on  general  or  local  causes ;  but  in  every 
case,  this  treatment  should  be  very  careful,  and  it 
will,  in  some  instances,  have  to  be  protracted.  In 
these  cases,  where  there  is  a  discharge  through  the 
fang  of  the  tooth,  such  treatment  should  be  adopted, 
as  will  most  speedily  and  effectually  suppress  it;  and 
if  it  proceeds  from  a  remaining  portion  of  the  nerve 
near  the  point  of  the  fang,  this  should  be  removed, 


EXPOSED    PULPS.  249 

and  such  application  made  as  will  prevent  a  recur- 
rence of  the  discharge,  and  assist  the  part  to  re- 
cover its  health.  The  discharging  surface  may  be 
broken  up  by  cutting  it  away  with  an  instrument, 
or  be  destroyed  with  an  escharotic — either  nitrate 
of  silver,  creosote,  or  chlorid  of  zinc,  in  the  use  of 
which,  several  applications  will,  in  many  cases,  be 
necessary.  From  their  action,  the  secreting  surface 
is  destroyed,  healthy  granulations  spring  up,  and  a 
normal  condition  is  established. 

The  discharge  should  be  wholly  suppressed  before 
the  tooth  is  filled ;  otherwise,  alveolar  abscess  would 
be  speedily  formed.  In  cases  where  there  is  peri- 
ostitis, it  must  be  subdued  before  the  tooth  will  tole- 
rate the  operation  of  filling.  To  attain  this  end, 
the  treatment  to  be  adopted  will  be  dictated  by  the 
nature  of  the  causes  which  operate  to  induce  the 
disease.  General  treatment  will  be  indicated  only 
when  there  is  a  constitutional  condition  favorable 
to  the  local  affection ;  but  where  there  is  no  such 
general  predisposition,  the  treatment  should  be  wholly 
local,  and  may  consist  of  the  following  or  similar 
appliances :  depletion,  either  by  leeching,  cupping, 
or  scarifying  the  gums  ;  or  counterirritation,  either 
by  scarifying,  or  by  the  application  of  highly  stimu- 
lating lotions.  Counterirritation  may  be  produced, 
also,  by  making  a  deep  incision  in  the  gum  oppo- 
site the  tooth  affected,  and  introducing  a  little  flock 


250  EXPOSED    PULPS. 

of  floss  or  cotton,  saturated  with  creosote,  which 
is  to  be  kept  in  place  till  the  inflammation  of  the 
periosteum  is  allayed;  which  will  be  effected  in  from 
one  to  five  days.  The  silk  or  cotton  should  be 
changed  every  day,  till  the  restoration  of  the  tooth 
to  health  is  affected,  when  it  is  to  be  removed,  and 
the  wound  permitted  to  heal.  Mild  stimulating 
applications  to  the  gums  in  the  immediate  vicinity, 
so  as  to  increase  the  circulation,  will,  in  some  cases, 
be  all  that  is  required.  A  vapor  bath,  or  warm 
water  applied  to  the  part,  is  often  beneficial ;  and,  in 
some  cases,  a  continued  application  of  cold,  by  means 
of  ice-water,  will  subdue  inflammation  of  the  perios- 
teum. Indeed,  any  antiphlogistic  treatment  that  can 
be  adopted  advantageously,  may  be  employed  in 
periostitis. 

The  periostitis  of  teeth  whose  nerves  are  dead,  com- 
monly has  its  origin  at  the  point  of  the  fang,  from  irri- 
tation induced  in  the  outstart  by  the  dead  and  decom- 
posing pulp  and  other  matter  at  that  point.  In  many 
instances,  the  inflammation  is  not  confined  to  the 
fang  of  the  tooth  on  which  it  began ;  but  it  will 
extend  to  the  alveolus,  the  gums,  and  the  periosteum 
of  the  neighboring  teeth.  Whenever  the  existence 
of  this  disease  is  suspected,  and  yet  not  very  appa- 
rent, as  is  often  the  case,  the  examination  should  be 
very  thorough.  In  some  instances,  a  striking  of  the 
tooth  at  one  particular  point  and  at  a  certain  angle, 


EXPOSED    PULPS.  251 

will  produce  pain  ;  whereas,  percussion  on  any  other 
part  of  the  tooth,  or  at  any  other  angle,  will  cause 
none  at  all.  By  an  exercise  of  care  and  discrimina- 
tion, the  exact  point  of  disease,  if  confined  to  a  small 
space,  may  be  ascertained.  For  instance,  if  striking 
on  the  labial  surface  of  a  central  incisor  near  the 
point,  produces  pain  in  the  socket,  while  striking  on 
any  other  point  would  not,  the  place  of  the  inflam- 
mation is  the  anterior  portion  of  the  fang,  at  or  near 
its  point.  By  such  means,  the  skilful  and  discern- 
ing will  be  enabled  to  form  a  tolerably  accurate 
opinion  as  to  the  extent  and  location  of  periostitis 
in  all  cases ;  and  this  is  an  important  consideration ; 
for,  if  inflammation  is  found  confined  to  a  small  por- 
tion of  a  fang,  the  treatment,  if  local,  should  be  as 
near  that  point  as  possible. 

Inflammation  of  the  periosteum  may  sometimes  be 
induced  by  the  presence  of  foreign  substances  forced 
down  between  the  free  margin  of  the  gum  and  the 
neck  of  the  tooth,  which  have  remained  there  till 
they  have  become  vitiated,  so  as  injuriously  to  affect 
the  gums  and  periosteum.  A  deposit  of  salivary  cal- 
culus sometimes  produces  inflammation  of  the  gums 
and  periosteum.  Teeth  otherwise  healthy  are,  in 
some  instances,  thus  affected;  though  those  which 
have  lost  their  internal  vitality,  are  much  more  liable 
to  such  disease. 

Preparing  the   Teeth  for  F'tU'axj. — After  the  tooth 


252  EXPOSED    PULPS. 

has  been  brought  to  a  healthy  condition,  the  decayed 
cavity  is  first  to  be  excavated  and  made  of  proper 
form,  the  pulp-chamber  to  be  shaped,  and  then  the 
canals  and  the  fangs  to  be  prepared  for  filling.  For 
the  preparation  of  decayed  cavities  here,  the  directions 
given  on  that  subject  hitherto,  will  be  quite  sufficient. 
In  the  formation  of  the  pulp-chamber,  the  abrupt 
projecting  portions  of  dentine  should  be  cut  down ; 
and  if  there  is  any  decomposition  of  this,  it  should 
be  removed.  The  pulp -chamber  may  be,  when  it  is 
excavated,  of  a  general  retaining  form,  or  there  may 
be  retaining  points  made  within  it  at  proper  situa- 
tions. In  the  preparation  of  the  canals  in  the  fangs, 
some  operators  do  nothing  more  than  cleanse  them 
out  thoroughly.  An  other  method  is,  to  pass  fine 
bur-drills  into  them  as  far  as  practicable,  thus  making 
the  opening  of  the  same  size  all  the  way;  or  to  scrape 
out  the  canal  with  a  fine  No.-lO  excavator.  Very 
fine,  delicate  instruments  are  required  for  cleansing 
out  and  forming  the  canals;  and  they  should  be  quite 
elastic  and  of  low  temper.  Instruments  for  this  pur- 
pose, are  sometimes  made  of  gold  wire,  to  obviate 
the  liability  to  break  off  in  the  tooth.  But  the  best 
method  of  forming  these  canals,  is  with  a  three-  or 
four-sided  broach,  tapering  to  a  sharp  point,  and  its 
inclination  corresponding,  as  far  as  possible,  with 
that  of  the  fang.  This  instrument  is  employed  to 
enlarge  the  canal,  and  give  it  a  regular  shape;  and 
a  variety  should  be  at  hand,  so  that  one  of  the  proper 


EXPOSED    PULPS.  253 

size  and  taper  can  be  selected.  In  cleansing  and 
forming  the  canal,  care  is  necessary  to  prevent  the 
instrument  from  passing  entirely  through  the  point 
of  the  fang.  Such  an  accident  is  not  very  liable  to 
occur  with  the  tapered  broach ;  but  with  the  minia- 
ture excavator  or  barbed  wire,  it  is, — especially  in 
the  teeth  of  the  young,  where  the  foramina  through 
the  fangs  are  large;  and  it  is  peculiarly  apt  to  happen 
to  the  incisors,  the  canines,  and  the  palatine  roots  of 
the  superior  molars.  But,  after  the  complete  develop- 
ment of  the  teeth,  there  is  no  excuse  for  an  accident 
of  this  kind ;  for  then  there  is  an  abrupt  contraction 
of  the  canal  near  the  point  of  the  fang,  which  may 
always  be  detected  by  a  careful  introduction  of  the 
instrument. 

The  decayed  and  pulp  cavities  and  the  canal  all 
being  thus  prepared,  are  now  ready  to  receive  the 
filling.  For  filling  the  fang,  there  are  several 
methods ;  one  of  which  is,  to  prepare  small  strips  of 
gold,  of  two  or  four  thicknesses  of  foil,  take  these  on 
the  point  of  an  instrument,  and  pack  them  into  the 
fang,  in  successive  folds,  till  the  canal  is  full. 
An  other  method  is,  to  take  small  portions  of  gold,  and 
pack  them  in,  one  on  an  other,  till  the  fang  is  full. 
An  other  is,  to  take  strips  of  from  two  to  four  thick- 
nesses, and  from  one  to  two  lines  wide,  and  roll  them 
on  a  fine  broach  in  such  a  manner  as  to  make  a  cone- 
shaped  block,  a  little  longer  than  the  depth  of  the 
canal  to  be  filled,  and  of  the   same   taper ;  quite  a 


254  EXPOSED    PULPS. 

number  of  these  blocks  will  be  required  for  any  given 
case,  of  various  sizes,  lengths,  and  densities ;  the 
longest,  largest,  and  least  dense  should  be  first  used, 
the  last  requiring  to  be  of  less  size  and  greater  density. 
These  cones  may  be  made  as  dense  as  desirable  by 
rolling  them  firmly  between  the  thumb  and  fingers, 
after  having  taken  them  off  the  broach.  They  are 
taken  up  and  introduced  with  the  plugging  pliers, 
and  passed  up  as  near  to  the  point  of  the  fang  as 
consistent  with  safety.  In  some  instances,  there  is 
danger  of  thrusting  them  through  the  point ;  and, 
in  order  to  prevent  this,  the  end  of  the  first  block 
introduced  may  be  made  so  large  that  it  will  not 
pass  through,  even  when  forced  up ;  or,  what  is 
probably  better,  a  very  small  round  pellet  of  gold 
may  be  forced  up  the  canal,  as  near  to  the  point  of 
the  fang  as  admissible,  so  as  to  serve  to  set  the  ends 
of  the  blocks  upon,  and  prevent  them  from  passing 
too  far  up.  The  cone-shaped  blocks  may  be  intro- 
duced and  consolidated  with  an  instrument  of  the 
same  general  form  as  the  canal,  but  much  smaller. 
This  kind  of  instrument  should  be  made  of  un- 
tempered  steel ;  though  some  operators  make  them 
of  whalebone,  to  prevent  breaking  off  in  the  fang, — 
an  unnecessary  precaution,  since  no  skillful  operator 
would  ever  break  off  a  low-tempered,  well-polished, 
properly-formed  instrument  of  this  kind.  After  a 
block  is   placed    in    the   cavity,   this    instrument    is 


EXPOSED    PULPS.  255 

thrust  in  by  its  side,  thus  consolidating  the  gold  to 
the  side  of  the  cavity.  Thus,  the  blocks  are  success- 
ively introduced  and  consolidated,  till  the  canal  is 
filled.  It  is  better  so  to  arrange  as  to  introduce  the 
last  portion  of  gold  near  the  center  of  the  canal, 
rather  than  at  a  side.  The  last  blocks  introduced 
should  be  stiff  and  dense,  that  they  may  be  thrust  in 
with  considerable  force. 

Another  method  of  preparing  the  gold  for  filling 
fangs  is,  to  take  the  pure  metal,  and  roll  it  down,  on  a 
good  rolling-mill,  as  thin  as  possible,  keeping  it  well 
annealed  ;  and  of  this,  form  the  cones,  and  introduce 
them  as  already  directed.  Made  in  this  way,  they 
are  stiffer,  and  fill  up  much  more  rapidly,  than  when 
made  of  foil.  They  are  to  be  condensed  in  the  same 
manner.  Where  the  canal  has  been  formed  with  a 
tapered  broach,  it  may  be  filled  with  a  gold  wire, 
made  of  the  same  size  and  taper  of  the  broach  ;  and 
this  wire  may  be  cut  off  at  the  orifice  of  the  canal,  or 
left  protruding  more  or  less  into  the  decayed  cavity, 
and  be  covered  up  with  the  filling. 

Some  other  substances  have  been  thought  quite  as 
suitable  for  filling  the  fangs  of  teeth,  as  gold.  Lead 
has  been  employed  for  this  purpose;  but  the  prin- 
cipal difficulty  with  this  is,  to  get  it  into  such  a  con- 
dition as  to  be  used  with  facility;  but,  if  as  com- 
pletely introduced,  it  would  probably  answer  the 
purpose  quite  as  well  as  gold.     Tin  foil  is  also  used 


256  EXPOSED    PULPS. 

for  this  purpose,  and,  under  favorable  circumstances, 
with  success.  Some  experiments,  too,  have  been 
made  with  plaster  of  Paris  and  similar  substances, 
for  filling  fangs  and  pulp  cavities ;  but  with  what 
success,  it  is  not  ascertained — some  claiming  instances 
of  success,  and  others  reporting,  in  every  instance, 
failure;  so  that  there  are  not  sufficient,  data  to  war- 
rant the  adoption  of  any  of  these  substances  into 
practice. 

In  cases  in  which  there  is  liability  to  irritation, 
the  operation  of  tilling  a  fang  is  quite  enough  for  one 
sitting ;  and  in  any  case,  not  more  than  three  fangs 
should  be  filled  at  one  sitting.  The  filling  of  a  large 
pulp-cavity  will  occupy  one  sitting,  and  that  of  the 
decayed  cavity,  an  other.  When  a  respite  is  thus 
had  between  the  filling  of  the  pulp  cavity,  and  that 
of  the  decayed  cavity,  the  former  should  be  dressed 
down  perfectly  solid  and  smooth,  so  that  no  moisture 
may  penetrate  it;  and  then,  when  the  latter  is  to  be 
introduced,  the  surface  of  the  former  should  be  rough- 
ened by  being  cut  up  with  a  sharp  instrument,  or  by 
being  indented  with  small  retaining  pits,  so  as  to  lay 
hold  of  and  fasten  the  last  filling.  From  one  to  four 
days  should  intervene  between  the  different  divisions 
of  the  operation.  The  filling  of  the  decayed  cavity 
is  to  be  performed  according  to  the  directions  already 
given.  When  inflammation  ensues  on  an  operation 
of  this  kind,  recourse  is  had  to  the  treatment  already 


EXPOSED    PULPS.  257 

described  for  preventing,  counteracting,  or  reducing 
inflammation. 

Some  experiments  have  been  made  to  test  the 
effect  of  restoring  the  parts  to  health,  forming  a  cica- 
trice at  the  point  of  the  fang,  cleansing  this  out,  fill- 
ing the  pulp  cavity  and  the  cavity  of  decay,  and 
leaving  the  canal  unfilled ;  and  it  is  maintained  that 
this  method  will,  in  favorable  cases,  answer  the  pur- 
pose quite  as  well  as  that  of  filling  the  fang,  and 
incur  less  risk.  The  treatment  will  be  such  as 
already  described  for  the  restoration  of  diseased 
fangs ;  all  discharge  through  the  fang  must  be  sup- 
pressed, and  all  foreign  substances  liable  to  decom- 
position, removed  from  the  canal,  so  that  there  may 
be  a  complete  restoration  before  this  is  closed. 

In  case  a  discharge  of  pus  is  made  into  the  canal 
after  a  tooth  has  been  thus  treated  and  filled;  in  case 
a  decayed  cavity  has  been  filled  before  the  complete 
suppression  of  the  discharge ;  or  in  case  a  tooth  is 
filled,  and  the  pulp  afterward  dies :  in  either  of  these 
cases,  it  is  necessary  to  make  a  vent  for  the  escape  of 
the  pus.  This  is  done  by  passing  a  small  drill  into 
the  pulp  chamber  or  canal,  just  above  the  filling,  as 
close  as  possible.  The  handle  of  the  drill  should  be 
depressed,  so  as  to  give  the  opening  a  downward 
inclination  from  within  outward,  and  thus  favor  the 
escape  of  any  secretion. 

In  the  superior  molars,  this  opening  may  be  made 


258  EXPOSED    PULPS. 

through  the  fang.  It  is  to  be  made  through  the 
masticatory  surface ;  it  may,  sometimes,  be  in  the 
depressions  on  the  crown  surface,  even  though  there 
be  no  filling.  In  incisors,  it  is  made  through  the 
palatine  portion  of  the  crown.  It  is  better,  however, 
in  all  cases,  to  make  an  opening  of  this  kind  through 
the  neck  of  the  tooth,  just  under  the  free  margin  of 
the  gum,  since  here  foreign  substances  are  not  so 
liable  to  be  crowded  into  it,  as  where  it  is  through 
the  masticatory  surface.  In  cases  in  which  it  is 
obvious  at  the  time  of  filling  the  tooth,  that  such  an 
opening  will  be  required,  it  is  better  to  make  it  before 
the  filling  is  introduced,  as  follows  :  first,  prepare 
the  decayed  and  pulp  cavities  for  filling ;  then  drill 
through  the  neck  of  the  tooth,  into  the  canal,  to  the 
extreme  part  of  the  pulp  chamber ;  and  finally,  intro- 
duce into  this  hole,  its  entire  depth,  a  piece  of  smooth 
steel  wire,  such  as  will  closely  fit,  leaving  it  exposed 
through  the  decayed  cavity — and  if  it  is  not  enough 
exposed  when  introduced,  the  tooth-bone  may  be  cut 
away  about  it,  till  it  is  fully  exposed ;  when  the 
decayed  and  pulp  cavities  are  filled  in  the  usual 
manner,  and  condensed  solidly  against  the  wire. 
After  the  filling  is  finished,  the  wire  is  withdrawn, 
leaving  a  smooth,  continuous  opening  for  the  escape 
of  any  secretion  that  may  collect  within.  When  the 
opening  into  the  canal  is  not  made  till  after  the  tooth 
is  filled,  there  is  liable  to  be  a  space  between  it  and 


ALVEOLAR    ABSCESS.  259 

the  filling,  that  will  fill  up  with  fetid  matter,  and 
become  very  offensive. 

ALVEOLAR    ABSCESS. 

Alveolar  abscess  is  produced,  in  the  first  place, 
by  the  formation  of  a  secreting  sac  at  or  near  the 
point  of  the  fang ;  or,  in  the  molar  teeth,  frequently 
in  the  bifurcation.  The  secretions  of  these  sacs  are 
different  in  character,  according  to  the  different  con- 
ditions of  the  parts  about.  Sometimes,  the  discharge 
from  these  sacs  is  from  the  fang ;  sometimes  from 
between  the  tooth  and  the  alveolus ;  and  sometimes, 
directly  through  the  alveolus  and  gums.  There  are 
occasional  cases  in  which  the  discharge  will  be  at 
a  very  considerable  distance  from  the  point  of  secre- 
tion ;  but,  in  such  cases,  the  secretion  always  fol- 
lows some  natural  avenue  that  affords  a  facility  for 
its  passage — as,  for  instance,  along  a  suture.  There 
are  two  or  three  cases  recorded  where  the  issue  from 
an  abscess  of  the  central  incisor  was  near  the  poste- 
rior portion  of  the  hard  palate  ;  and,  in  these,  the 
channel  of  the  pus  lay  along  the  suture  of  the  palate 
bones.  Sometimes,  the  opening  from  an  abscess  of 
the  first  or  second  molars  will  be  opposite  the  bicus- 
pids on  the  buccal  portion  of  the  gum.  Alveolar  ab- 
scess is  exceedingly  variable  in  character,  according 
to  the  constitutional  peculiarities  and  susceptibilities 
of  the  patient,  the  condition  of  the  parts  immediately 


260  EXPOSED    PULPS. 

adjacent,  and,  to  some  extent,  the  cause  which  has 
produced  it.     In  a  good  constitution,  after  an  abscess 
is  formed,  it  will   discharge  healthy  pus.     Occasion- 
ally, yet  very  seldom,  does  nature  alone  effect  a  per- 
manent cure.     In   constitutions  of  a  cachectic   dia- 
thesis, alveolar  abscess  is  liable  to  constant  discharge 
of  an  unhealthy  pus,  or  purulent  acrid  matter ;  and 
the  parts  about  it  are  usually  in  a  diseased  condition. 
The  cases  in  which  alveolar  abscess  is  most  likely 
to  occur  are  those  of  a  manifest  inflammatory  diath- 
esis, or  those  in   which   there  is  considerable  local 
inflammation,   from   some  local  exciting   cause.     In 
the  cases  of  constitutional  predisposition,  the  abscess 
assumes  a  chronic  character,  constantly  secreting  and 
discharging  pus,  but   does  not  usually  cause  much 
pain,  though  the  tooth  from  which  it  proceeds  will 
experience  some  soreness  and  an  uneasy  sensation.    In 
the  acute  forms  of  it,  however,  there  will  be  intense 
pain.    In  some  cases,  the  sac  will  be  found  producing 
its  specific  effects  without  much  irritation  of  the  sur- 
rounding parts ;  while  in  others,  there  will  be  main- 
tained  in  them  a  high  state  of  irritation,  which  is 
liable,  also,  to  extend  to  parts  more  remote,  especially 
if  there   are   any  irritating  agents   at   work.      Very 
seldom,  if  ever,  are  the  parts  involved  in  an  abscess, 
restored  by  unaided  nature  to  perfect  health. 

The  common  cause  of  abscess  is  the  presence  of 
irritating  matter  in  the  canal  at  the  point  of  the  fang, 


ALVEOLAR    ABSCESS.  261 

which,  no  doubt,  in  many  cases,  extends  through  the 
foramen  at  that  point,  inducing  inflammation,  and 
resulting  in  abscess.  Usually,  the  sac  is  found  at 
the  point  of  the  fang  ;  but,  sometimes,  it  is  located 
on  the  side,  the  point  remaining  comparatively  free. 
In  the  molars,  particularly  the  superior  ones,  the  sac 
will  frequently  be  found  in  the  bifurcation,  often 
occupying  the  entire  space  between  the  fangs.  When 
it  is  on  the  point  of  one  of  the  fangs,  this  is  usually 

Fi£.  34. 


the  palatine.     Fig.  34  represents  the  position  of  the 
sacs  on  the  roots  of  the  different  teeth. 

Treatment.  The  treatment  of  alveolar  abscess  will 
be  governed  by  the  constitution  of  the  patient  and 
the  condition  of  the  part  affected ;  a  case  of  recent 
origin  will  yield  much  more  readily  than  one  of  long- 
standing. "When  a  case  has  assumed  the  chronic 
form,  and  the  surrounding  parts  have  become  impli- 
cated in  the  diseased  condition,  a  restoration  to 
health  is  often  very  difficult.  Indeed,  till  within  a 
few    years,    the    removal   of    alveolar    abscess    was 


262  EXPOSED    PULPS. 

thought  to  be,  as  a  general  thing,  wholly  imprac- 
ticable. But,  by  the  treatment  now  employed,  this 
affection  is  readily  cured,  unless  the  parts  in  the 
immediate  vicinity  are  very  much  involved.  In 
some  cases,  the  sac  on  the  point  of  the  fang  is  very 
large,  and  absorption  has  taken  place,  to  accommo- 
date it ;  and,  though  in  many  such  instances,  the  sac 
might  be  destroyed,  yet  the  space  occupied  by  it 
would  not  be  filled  up  with  a  healthy  deposition. 
In  young  persons,  when  an  abscess  is  formed  on  the 
point  of  a  fang,  especially  in  the  single-fang  teeth  of 
the  superior  .  maxillar,  the  discharge  is  frequently 
through  the  tooth,  in  consequence  of  the  large  size  of 
the  foramen  of  the  point  of  the  fang ;  and  generally, 
in  such  cases,  the  local  treatment  may  be  made 
through  the  canal.  Sometimes  the  discharge  is  be- 
tween the  fang  and  the  wall  of  the  alveolus.  More 
often,  however,  especially  in  persons  over  twentyfive 
years  of  age,  the  discharge  is  through  the  alveolus  and 
the  soft  parts  to  the  surface,  by  the  shortest  course. 

When  an  alveolar  abscess  is  influenced  by  cachexy 
or  any  other  constitutional  derangement,  general 
treatment  must  be  resorted  to,  such  as  the  condition 
indicates.  The  local  treatment  always  demanded,  is 
such  as  will  break  up  and  destroy  the  secreting  sac. 
This  is  effected  either  by  surgical  or  by  therapeutic 
treatment,  and  frequently  in  chronic  cases,  by  both 
together;  but,  in  the  great  majority  of  acute  cases, 


ALVEOLAR   ABSCESS.  263 

therapeutic  treatment  alone  will  be  sufficient.  In 
order  to  break  up  an  abscess  by  an  operation,  it  must 
be  easy  of  access;  and  it  is  very  seldom  that  an 
operation  of  this  kind  can  be  performed  through  the 
fang  of  a  tooth ;  but,  fortunately,  in  almost  all  those 
cases  where  the  discharge  is  through  the  fang,  thera- 
peutic treatment  alone  will  answer  the  purpose. 
When  the  point  of  discharge  is  on  the  gum  opposite 
the  secreting  sac,  a  sharp-pointed  bistoury  should  be 
used,  and  the  canal  of  discharge  sufficiently  opened 
to  admit  the  free  use  of  the  instrument  at  the  seat 
of  the  disease.  Then  the  secreting  sac  should  be 
dissected  from  the  point  of  the  fang,  and  its  connec- 
tion with  the  circulation  severed  as  completely  as 
possible,  thus  cutting  off  its  supply.  After  this,  if 
the  case  is  a  favorable  one,  nature  may  be  left  to 
accomplish  the  work  ;  in  which  case,  the  broken-up 
sac  will  be  thrown  off,  healthy  granulations  will  be  de- 
veloped, and  the  parts  be  restored  to  complete  health. 
In  other  cases,  however,  after  an  operation,  nature 
unaided  will  not  complete  the  cure ;  but  such  thera- 
peutic treatment  must  be  resorted  to,  as  the  circum- 
stances seem  to  require.  In  some  cases,  the  opening- 
through  the  alveolus  will  need  to  be  enlarged ;  and 
this  part  of  the  operation  demands  great  care.  All 
particles  of  bone  should  be  removed  from  this  open- 
ing, since,  if  permitted  to  remain,  they  would  pro- 
duce irritation  and  tend  to  increase  the  difficulty. 


264  EXPOSED    PULPS. 

When  the  therapeutic  treatment  is  applied  through 
the  fang,  the  canal  is  to  be  cleansed  of  all 
foreign  and  detached  matter,  and  opened  freely 
through  to  the  point ;  and,  if  the  discharge  is  very 
fetid,  some  disinfectant  should  -  be  used,  as  chlorid  of 
sodium  or  of  zinc,  since  a  fetid  condition  keeps  up 
irritation.  -  The  cleansing  of  the  fang  may  be  accom- 
plished by  injection  of  chlorid  of  sodium;  after  which, 
the  agent  to  act  on  the  disease  at  its  seat,  is  to  be 
introduced.  Of  this  agent,  there  are  various  kinds 
employed,  the  chief  of  which  are  chlorid  of  zinc, 
nitrate  of  silver,  and  creosote,  the  first  being  applied 
in  the  solid,  and  the  latter  two  in  the  liquid  state — 
though  the  nitrate  may  be  employed  in  the  form  of 
crystal.  The  method  of  using  the  chlorid  is,  to  pass 
it  in  small  portions  up  the  canal,  on  a  piece  of  silk, 
with  a  fine  probe,  entirely  through  the  point  of  the 
fang ;  which  process  should  be  repeated  from  two  to 
six  times,  in  as  many  days.  After  this,  during  two 
or  three  days,  floss  silk,  moistened  with  a  mild  solu- 
tion of  creosote  and  tannin  in  alcohol,  should  be 
applied  daily  ;  and  then  clean  silk  or  cotton  may  be 
worn  in  the  canal,  changed  every  day,  for  three  or 
four  days,  or  till  it  is  manifest  that  there  is"  no  longer 
any  discharge,  and  that  the  parts  are  in  a  healthy 
condition.  If  nitrate  of  silver,  in  solution,  or  creosote 
is  used,  it  should  be  absorbed  into  a  piece  of  floss  silk, 
and  passed  through  the  fang  in  the  manner  already 


ALVEOLAR    ABSCESS.  265 

described.  The  nitrate  is  more  prompt  of  action 
than  creosote,  and  will  accomplish  a  specific  object  in 
a  shorter  time.  Either  of  these  solutions  may,  by 
the  use  of  a  syringe,  be  very  effectively  thrown 
through  a  fang  in  the  following  manner :  fill  the 
opening  into  the  fang  with  gutta  percha ;  drill 
through  it  a  hole  large  enough  to  receive  tightly  the 
point  of  the  syringe ;  and  then,  charging  with  the 
solution,  inject  it  through  the  fang ;  and,  in  cases 
where  there  is  an  opening  through  the  gum,  the 
injection  may  be  forced  round  through  this.  The 
condition  of  the  parts  will  indicate  how  long  this 
kind  of  treatment  should  continue.  Ordinarily, 
when  the  discharge  is  entirely  through  the  gum, 
the  bistoury  should  be  used  to  enlarge  the  opening. 
In  many  cases,  therapeutic  treatment  alone  will 
accomplish  the  object ;  and,  when  the  opening  to  the 
sac  is  large  and  direct,  the  therapeutic  agents  may  be 
introduced  through  it  right  to  the  seat  of  disease.  If 
nitrate  of  silver,  in  solution,  or  creosote  is  used,,  it 
should  be  introduced  to  the  point  of  affection  on  a 
pledget  of  cotton  or  floss,  as  heretofore  directed  ;  or 
if,  as  is  preferable,  chlorid  of  zinc  or  nitrate  of  silver 
in  solid,  it  should  be  passed  through  the  opening  into 
contact  with  the  sac.  This  treatment  should  be  kept 
up  till  the  indications  are  fulfilled. 

In  the  treatment  of  abscess  of  the  inferior  maxilla 
much  difficulty  is  often  experienced  from  a  want  of 


266  EXPOSED    PULPS. 

free  egress  for  the  secretion  :  while,  in  the  superior 
teeth,  the  pus  may  frequently  escape  through  the 
tooth  by  gravitation,  this  force,  in  the  inferior  jaw, 
increases  the  difficulty.  The  sac  being  usually 
formed  on  the  point  of  a  fang,  the  secretion  then  rests 
at  the  bottom  of  the  socket,  and  is  frequently  pent 
up  there  till  it  finds  an  outlet  through  the  gum, 
somewhere  between  the  point  of  the  fang  and  the 
neck  of  the  tooth.  It  is,  in  many  instances,  very 
difficult  to  get  an  opening  as  low  down  as  the  point 
of  the  fang,  since  the  buccal  attachment  to  the  gum 
is  usually  quite  above  the  point  of  the  fang,  particu- 
larly in  the  case  of  the  molars  and  second  bicuspids. 
Very  seldom,  if  ever,  can  a  secreting  sac  on  the  fang 
of  an  inferior  tooth  be  destroyed  by  treatment  applied 
through  the  canal  of  the  root.  Some  are  accustomed 
to  make  a  vertical  incision  of  the  gum,  as  low  as  the 
point  of  the  fang,  and  perforate  the  alveolus,  and 
treat  through  this  channel,  as  already  described. 
Owing  to  the  disadvantage  abovementioned,  much 
more  energetic  treatment  is  necessary  to  attain  suc- 
cess with  the  abscess  of  the  inferior  than  with  that  of 
the  superior  teeth. 

In  the  great  majority  of  cases,  where  one  third  or 
more  of  the  periosteum  of  a  root  is  involved  in 
abscess,  the  indications  certainly  point  to  the  re- 
moval of  the  tooth.  In  the  lower  teeth,  a  very 
serious   difficulty    occasionally   occurs    from    abscess, 


ALVEOLAR   ABSCESS.  267 

namely,  an  external  opening  and  discharge  ;  and  in  all 
cases  where  this  condition  has  already  been  reached, 
the  offending  tooth  should  be  removed.  But,  when 
such  a  result  is  only  anticipated,  and  is  yet  contin- 
gent, treatment  may  be  employed  to  avert  it ;  and, 
in  order  to  this,  a  deep  and  free  incision  should  be 
made  in  the  gum,  opposite  the  affected  tooth,  and 
poultices  applied  within ;  and,  where  there  is  ex- 
ternal swelling,  pressure  is  recommended,  as  follows  : 
adjust  a  piece  of  thick  sheet-lead  to  the  part,  and 
make  the  pressure  on  this  by  means  of  a  bandage 
comprising  it  and  passing  round  the  head.  It  is 
supposed  that  this  application  counteracts  the  gravi- 
tation of  the  secretion,  pressing  it  upwards,  and  thus 
inducing  it  to  seek  an  outlet  at  some  more  desirable 
point.  If  it  is  a  worthless  tooth  that  is  producing  a 
difficulty  of  this  kind,  it  should  be  removed  at  once. 
In  regard  to  the  treatment  of  alveolar  abscess, 
much  yet  remains  to  be  learned.  With  the  attain- 
ments thus  far  made  in  this  direction,  no  aspiring 
dentist  will  rest  satisfied. 


CHAPTER  X. 

PIVOT    TEETH. 

Whenever  the  crowns  of  anterior  teeth  have 
become  so  much  decayed  that  they  can  not,  by  fill- 
ing, be  rendered  useful,  they  may,  under  favorable 
circumstances,  be  supplied  by  artificial  crowns  con- 
structed on  the  roots.  For  the  successful  accom- 
plishment of  this  work,  the  following  conditions  are 
important :  1.  The  constitution  of  the  patient  should 
be  good.  2.  The  mouth  should  be  in  a  healthy  con- 
dition, and  without  diseased  teeth  or  roots.  3.  The 
teeth  should  be  free  from  calcareous  deposits  and 
from  all  foreign  substances  liable  to  induce  irritation 
or  inflammation.  4.  The  attachment  of  the  teeth 
should  be  perfect  and  healthy.  5.  It  is  desirable 
that  the  root  have  a  living,  healthy  nerve  remaining. 
6.  The  root  above  the  neck  should  be  sound.  7. 
The  root  should  occupy  a  correct  position  in  the 
arch.  Prior  constitutional  treatment  will  often  be 
required  where  there  are  unfavorable  conditions. 

The  fangs  of  the  six  superior  anterior  teeth  are 
better  adapted  for  the  reception  of  these  crowns,  than 


PIVOT   TEETH.  269 

those  of  any  other  in  the  mouth.  The  fangs  of  the 
first  bicuspids  frequently  terminate  in  two  points,  and 
are  always  more  or  less  compressed,  so  that  they  will 
not  receive  a  pivot  large  enough  to  sustain  a  crown  ; 
besides,  these  teeth  are  masticatory,  and  crowns 
pivoted  to  them  very  soon  become  loose  and  useless. 
The  roots  of  the  inferior  incisors  are  also  compressed, 
and  thus  subject  to  the  same  disability.  Occasion- 
ally, however,  pivot  crowns  are  attached  to  the  roots 
of-the  superior  bicuspids,  and  the  inferior  incisors, 
cuspids,  and  bicuspids.  But  in  order  that  such  an 
operation  shall  be  of  any  utility,  the  conditions  must 
be  favorable,  the  roots  with  as  little  lateral  compres- 
sion as  possible,  in  a  very  sound  and  healthy  state, 
and  without  any  tendency  to  inflammation. 

The  preparation  of  the  root  for  the  reception  of  an 
artificial  crown,  is  a  very  simple  process.  It  will, 
however,  be  somewhat  modified  by  the  kind  of 
crown  used,  and  the  method  of  attaching  it.  Ordi- 
narily, the  first  step  is,  to  remove  the  crown,  or  any 
remaining  portion  of  it,  with  a  fine  saw  or  excising 
forceps.  Of  this  latter  instrument,  there  are  various 
forms,  that  in  most  common  use  having  narrow, 
transverse  edges,  closing  squarely  together,  as  repre- 
sented in  Fig.  35.  With  these  forceps,  any  broken 
fragments  of  the  crown  can  be  removed  with  great 
facility.  Many  operators,  placing  their  edge  on  the 
neck  of  the  tooth,   are  accustomed    to    excise    with 


270 


PIVOT   TEETH. 


them  the  principal  part  of  the  crown  at  a  single  cut. 
This    method,    however,   is    objectionable,   since    it 


Fier.  35. 


always  gives  too  great  a  jar  to  the  root,  and  is  liable 
to  loosen,  and,  in  many  instances,  to  fracture  it,  so  as 
to  unfit  it  for  the  reception  of  the  crown.  But,  in 
every  case  in  which  an  artificial  crown  is  required, 
the  natural  crown  is  very  much  decayed ;  and,  in  this 
condition,  is  very  readily  removed  with  excising  for- 
ceps, nipping  it  off  in  fragments,  beginning  where  it 
is  weakest  and  thinnest,  and  encroaching  on  it  till  it 
is  all  cut  down — at  least,  as  far  as  the  forceps  are 
available.  Yet  care  is  necessary  even  in  this  man- 
ner of  using  the  forceps,  lest  the  root  be  fractured  or 
too  much  jarred. 

After  such  excision  with  the  forceps,  the  root  is  to 
be  dressed  down  for  the  reception  of  the  crown,  with 
a  round,  or,  better,  an  elliptical  file.  But,  for  this 
operation  of  removing  a  crown,  a  very  fine,  smooth, 


PIVOT   TEETH.  271 

narrow  saw,  set  in  a  frame  (Fig.  36),  is,  in  some 
respects,  preferable  to  the  forceps,  it  being  less  liable 
to  injure  the  root,  than  the  latter.     With  this,  the 

Fijr-  3G. 


crown  is  sawed  off  at  the  margin  of  the  gum,  leaving 
the  end  of  the  root  about  the  form  required  for  the 
reception  of  the  artificial  crown.  In  the  process,  the 
crown  being  sustained  by  the  fingers,  the  saw,  kept 
constantly  wet,  is  applied  to  the  tooth,  and  passed 
along  its  proximal  side  to  the  margin  of  the  gum, 
and  then  along  this  through  it,  cutting  it  off  at  right 
angles  with  its  axis.  After  the  crown  has  been  thus 
sawed  off,  the  root  is  fitted,  with  a  fine,  round  file, 
for  the  artificial  crown  ;  and,  ordinarily,  it  should  be 
dressed  at  right  angles  with  its  axis. 

At  this  stage  of  the  work,  if  the  nerve  remains 
alive,  it  should  be  removed ;  and  the  preferable 
method  is  by  direct  operation,  in  the  manner  already 
described  (p.  234).  It  is  better,  in  all  such  cases,  to 
avoid  the  use  of  arsenic  for  destruction  of  the  nerve. 
It  will  often  be  necessary  to  destroy  the  pulp  before 
the  crown  is  removed.  For  a  successful  operation,  it 
is  always  preferable  that  the  root  have  the  pulp 
living.     After  the  pulp  is  removed,  the  canal  is  to 


272  PIVOT   TEETH. 

be  enlarged  to  a  suitable  size,  with  the  appropriate 
drill.  If  there  is  any  remaining  sensitiveness  of  the 
dentine,  as  is  very  seldom  the  case,  the  bur  drill  may 
be  used  for  this  purpose ;  but  if  not,  then  the  com- 
mon spear-pointed  drill  will  be  best.  Where,  how- 
ever, the  canal  takes  the  form  of  a  mere  fissure, 
either  the  bur  drill  or  the  four-sided  broach  may  be 
employed.  The  depth  to  which  the  canal  should  be 
enlarged,  will  be  determined  by  the  length  of  the 
fang;  but  it  should,  in  all  cases,  be  sufficient  firmly 
to  retain  a  pivot — which  is  from  one  to  two  lines; 
and  the  diameter  of  the  hole  will  be  modified  by  the 
size  of  the  root.  The  drills  should  be  frequently 
moistened  with  water,  to  prevent  their  clogging. 
The  shaft  of  the  instrument,  in  the  operation,  should 
be  in  a  line  with  the  cutting  edges  of  the  two  adjoin- 
ing teeth,  and  midway  between  them ;  and  the  drill 
itself  should  follow  the  natural  canal  as  nearly  as 
possible. 

FITTING    THE    CROWN. 

The  tooth  selected  should  be  of  a  size,  shape,  and 
color  to  correspond  with  the  natural  crown  which  it 
is  to  represent.  It  should  not  be  ground  on  the 
sides  or  points ;  indeed,  ought  not  to  be  touched  with 
the  cinerywheel  at  all.  The  diameter  of  the  neck 
of  the  crown  should  correspond  with  that  of  the 
articulating  surface  of  the  root  to  which  it  is  to  be 


FITTING   THE    CROWN. 


attached.  In  fitting  the  crown  to  the  root,  the  point 
should  be  made  as  nearly  perfect  as  possible ;  for  the 
tooth  is  thus  more  permanent  and  comfortable;  an 
open  point  offers  a  receptacle  for  the  lodgment  of 
food  and  other  foreign  substances,  where  they 
become  vitiated,  and  produce  unpleasant,  if  not  inju- 
rious effects.  The  crown  may  be  principally  fitted 
to  the  root  without  pivot,  by  dressing  it  with  a  round 
or  elliptical  file,  and  frequently  trying  it  on  in  about 
its  proper  position.  After  having  been  thus  pretty 
accurately  fitted,  a  trying  pivot  of  soft  wood  should 
be  introduced,  by  means  of  which,  grinding  it  to  its 
exact  position,  the  crown  may  be  fitted  to  the  root. 

For  fitting  on  pivot  teeth,  Dr.  E.  Townsend  in- 
vented a  kind  of  round  or  convex  file,  with  a  con- 
cave counterpart,  into  which  the  file  exactly  fits; 
with  the  former  of  which  the  root  is  dressed,  and 
with  the  latter,  the  articulating  surface  of  the  crown. 
This  apparatus  would  be  very  good,  were  it  not  for 
the  great  difficulty  of  dressing  porcelain  teeth.  By- 
care,  a  very  complete  fit  can  be  made  with  a  round 
file  alone.  Some  coloring  material,  as  rose  pink,  for 
instance,  may  be  put  on  the  base  of  the  crown,  and 
then  the  tooth,  with  the  pivot  inserted,  set  in  its 
place — when  the  root  will  be  marked  where  the 
crown  has  touched  it,  and  can  be  dressed  at  the 
point  of  contact.  This  operation  is  repeated  till  a 
perfect  fit  is  attained.     This  method  is  to  be  recom- 


274  PIVOT    TEETH. 

mended  to  those  who  have  had  but  little  experience 
in  fitting  pivot  teeth. 

An  other  method  of  making  the  articulation  is,  to 
dress  the  end  of  the  root  square,  and  then  counter- 
sink it  about  half  a  line  deep  with  a  square-ended 
bur,  about  three  fourths  the  diameter  of  the  root. 
The  base  of  the  crown  is  then  ground  down,  by  the 
measure  of  the  bur,  perfectly  round,  so  as  exactly  to 
fit  into  the  depression  in  the  root.  The  bur  used  for 
countersinking  the  root  should  have  a  center-point  to 
fit  into  the  hole  in  the  fang,  and  thus  guide  the  instru- 
ment. This  method  of  fitting  on  crowns  is  objection- 
able, by  reason  of  its  too  great  exposure  of  the  root 
of  the  tooth.     Fig.   37   represents   the   bur  used  for 


this  purpose.     It  is  a  method  now  very  seldom  em- 
ployed. 

Still  an  other  method  of  making  an  articulation  is, 
to  dress  up  the  root  as  first  described ;  then  take  an 
impression  of  the  part  in  plaster  of  Paris  ;  and  from 
this,  get  a  model,  to  which  to  fit  the  crown.  This 
method,  however,  is  advisable  only  in  cases  where  it 
is  desirable  to  avoid  annoyance  to  the  patient  by  a 
tedious  fitting  process. 


ATTACHMENT   OF   THE    CROWN.  275 

ATTACHMENT    OF    THE    CROWN. 

The  means  of  attachment  in  most  common  use  is 
that  of  wood  pivots  ;  for  which,  wood  in  the  natural 
condition  is  ordinarily  employed,  though  it  is  much 
improved  by  compression.  The  kind  best  adapted 
for  pivots  is  the  fine-grain,  tough,  slow-growth  hick- 
ory, of  straight,  uniform  fiber,  which  should  be 
thoroughly  seasoned.  For  its  preparation,  take 
blocks,  six  or  eight  inches  long,  and  split  them  into 
rods,  about  one  fourth  of  an  inch  square ;  then,  with 
a  knife  and  file,  dress  them  down  to  a  size  one  third 
greater  than  that  of  the  intended  pivots ;  afterward, 
pass  them  through  three  or  four  holes  of  the  ordinary 
drawplate  inverted,  thus  making  them  of  uniform 
thickness  throughout ;  and  finally,  turning  the  draw- 
plate,  pass  them  through  it  in  the  same  manner  as 
wire,  continuing  till  the  rods  are  of  proper  size,  and 
all  the  pores  of  the  wood  are  closed  by  compression. 
They  should  be  slightly  oiled  before  being  drawn 
through  the  plate.  They  may  be  drawn  so  as  just 
to  fit  the  holes  of  the  artificial  crowns,  being,  of 
course,  of  different  sizes.  Pivots  thus  compressed  are 
stifle r,  stronger,  and  far  more  durable ;  and,  there 
being  greater  density  of  fiber,  there  are  less  absorp- 
tion of  moisture,  less  expansion,  and  less  liability  to 
decay,  than  in  wood  in  the  natural  condition. 

In  arranging  the  crown  in  position,  care  is  necess- 


276  PIVOT   TEETH. 

ary  to  prevent  it  from  being  struck  by  the  teeth  of 
the  opposing  jaw, — especially  since  it  often  happens, 
where  the  natural  crown  has  been  gone  for  some  time, 
that  the  corresponding  tooth  of  the  lower  jaw  becomes 
somewhat  elongated,  and  strikes  forcibly  against  a 
properly-adjusted  pivot  tooth.  Such  an  accident  is 
anticipated  either  by  filing  off  the  elongated  tooth,  or 
by  grinding  out  the  palatal  portion  of  the  artificial 
crown  sufficiently  to  accommodate  the  elongation. 
The  former  is  the  better  method,  and  should  always 
be  adopted  when  inflammation  of  the  dentine,  exposure 
of  the  pulp,  or  an  irascible  condition  of  the  surrounding 
parts,  does  not  forbid  it :  though,  in  many  instances, 
both  methods  may  be  advantageously  employed. 
But,  by  whatever  means,  the  antagonizing  teeth 
should  always  be  prevented  from  coming  in  contact 
with  the  artificial  crown ;  and  this  latter  should 
never  press  against  the  tooth,  on  either  side  of  it ; — 
indeed,  it  would  be  more  desirable  that  there  should 
be  a  small  interval  on  each  side. 

When  the  crown  is  in  its  proper  position,  the  hole 
in  the  root  and  that  in  the  crown  do  not  always  have 
precisely  the  same  direction  ;  in  which  case,  a  pivot 
will  be  required,  having  a  curvature  according  to  the 
variation  ;  and  the  extent  and  direction  of  such  in- 
flection, should  be  carefully  observed  while  adjusting 
the  crown  with  the  trying  pivot.  The  pivot  is  to  be 
neatly  and  accurately  fitted  into  the  crown  first,  and 


ATTACHMENT   OF   THE    CROWN.  277 

then  the  length  of  it  required  for  the  root,  ascertained 
with  the  gauge  represented  in  Fig.  38.     This  gauge 

Fie.  38. 


consists  of  a  wire  of  a  size  freely  to  enter  the  pivot-hole, 
having  a  little  slide  with  a  flange  attached.  By  in- 
troducing this  wire  into  the  pivot-hole,  the  slide  is 
pressed  back,  and  the  depth  of  the  hole  indicated  at 
once.  The  pivot  is  then  cut  off  accordingly,  and 
dressed  to  the  proper  size  and  inclination,  and  gently 
pressed  to  its  place  with  the  thumb  and  fingers. 
Before  being  introduced,  however,  it  may  be  wrapped 
with  gold  foil,  which  will  serve  to  protect  the  dentine 
of  the  root  from  decay,  and  also  to  preserve  the  pivot. 
Two  or  three  thicknesses  of  gold  foil,  too,  may  be 
placed  between  the  crown  and  the  root,  so  as  to  make 
a  more  perfect  joint  and  exclude  the  moisture.  There 
is,  however,  not  much  advantage  in  an  arrangement 
of  this  kind  ;  a  thin  sheet  of  Hill's  Stopping  placed 
in  the  joint,  makes  a  better  adaptation  than  the  gold, 
and  collodion  or  a  solution  of  chloroform  and  gutta 
percha  may  be  used  for  the  same  purpose.  The 
canal  in  the  root  above  the  pivot  should  be  filled  with 
gold  ;  though,  in  cases  where  there  is  a  discharge 
through  the  fan 2:,  this  would  not  be  admissible. 


278  PIVOT    TEETH. 

The  canal  at  the  orifice  is  sometimes  considerably 
enlarged  by  decay,  so  that  when  the  crown  is  fitted, 
and  the  canal  sufficiently  opened  for  the  reception  of 
the  pivot,  there  will  be  a  cone-shaped  space  which 
the  ordinary  pivot  will  not  fill.  There  are  several 
methods  of  obviating  this  difficulty ;  one  of  which  is, 
completely  to  fill  the  enlargement  with  gold,  and  then 
perforate  this  filling  with  the  proper-sized  drill  for  the 
reception  of  the  pivot ;  or,  which  would  be  better,  to 
introduce  into  the  canal  a  polished  steel  wire  of  the 
size  of  the  intended  pivot;  round  this  consolidate  a 
filling  of  gold,  having  first  made  retaining  points  at 
the  proper  places  in  the  dentine ;  finish  perfectly 
flush  with  the  end  of  the  root;  and  then  withdraw 
the  wire  from  the  canal,  and  it  is  ready  to  receive  the 
pivot  with  the  crown  attached.  Some  operators  form 
the  wood  pivot  of  such  a  shape  as  to  fit  into  and  fill 
the  enlarged  cavity.  An  other  method  is,  after  the 
pivot  is  fastened  into  the  crown,  to  build  round  it,  on 
the  base  of  this,  a  portion  of  Hill's  Stopping,  of  about 
the  size  and  form  of  the  enlargement  in  the  canal ; 
and  then,  the  tooth  being  ready  to  insert,  to  soften 
the  stopping  by  heat,  and  introduce  carefully  into 
place.  This,  when  skillfully  performed,  is  probably 
as  good  a  method  as  any  other. 

It  frequently  happens,  in  cases  where  the  nerve 
has  been  dead  for  a  considerable  time,  that  there  is 
more  or  less  discharge  through  the  canal  of  the  fang, 


METALLIC    PIVOTS.  279 

and  a  tooth  is  required  immediately,  or  at  least 
before  there  is  time  for  treatment  to  abate  the  dis- 
charge. To  such  a  condition  some  arrangement 
must  be  adapted,  so  as  not  entirely  to  close  up  the 
canal,  and  preclude  the  escape  of  pus.  For  this  pur- 
pose, a  groove  may  be  cut  down  the  wall  of  the 
canal,  or,  perhaps,  on  the  side  of  the  pivot  through- 
out its  length,  for  the  discharge  of  the  secretion. 
Where  there  is  irritation  or  liability  to  inflammation, 
a  temporary  pivot  of  soft  wood,  or  of  hard  wood 
loosely  fitted,  should  be  worn ;  for  thus  the  root  is 
less  jarred  by  percussion  on  the  crown,  and,  if  need 
be,  the  crown  and  pivot  can  be  removed. 

METALLIC    PIVOTS. 

The  liability  of  a  pivot  of  wood  to  wear  off  at  the 
point  between  the  crown  and  the  root,  as  well  as  to 
become  offensive,  and  the  difficulty  of  removing  the 
tooth,  have  led  dentists  to  seek  some  less  objection- 
able material ;  and  metals  have  been  experimented 
upon,  and  found  in  some  respects  preferable.  Gold 
has  been  employed  for  this  purpose  more  than  any 
other  metal.  Pivots  made  of  this  do  not  become 
offensive,  do  not  wear  off,  and  admit  of  any  desired 
curve,  and  of  an  easy  removal  of  the  crown.  There 
are  several  methods  of  attaching  this  kind  of  pivot 
to  a  tooth ;  and  a  very  common  one  is,  to  fit  into  the 


280  PIVOT    TEETH. 

hole  in  the  crown  a  piece  of  pivot  wood — cut  it  off 
even  with  the  base  of  the  crown,  and  perforate  it 
with  the  proper-sized  drill  for  the  reception  of  the 
metal  pivot,  which  may  be  roughened,  or  barbed  on 
some  of  its  sides,  and  then  forced  into  the  place  pre- 
pared for  it.  An  other  method  is,  to  drill  into  a 
block  of  wood ;  insert  the  pivot,  prepared  as  above, 
then  dress  down  the  wood  round  it  till  this  will  fit 
closely  into  the  crown ;  and,  after  it  is  pressed  in, 
cut  off  the  protruding  portion  of  wood.  In  either 
of  these  methods,  when  the  wood  becomes  moist, 
the  metal  pivot  will  be  very  firmly  retained. 
This  pivot  may  also  be  firmly  attached  to  the 
crown  by  soldering :  place  the  edge  of  the  tooth  in 
plaster  of  Paris ;  set  the  pivot  in  its  proper  position 
in  it;  fill  round  this  with  fragments  of  gold  plate, 
and  put  on  solder  and  borax;  heat  up  with  a  blow- 
pipe, and  draw  the  solder  to  the  bottom  of  the  cavity. 
An  other  method,  sufficient  for  all  practical  purposes, 
is,  to  set  the  pivot  in  place,  and,  packing  round  it  a 
stiff  amalgam  of  gold  and  mercury,  evaporate  the 
mercury  by  heat.  A  better  method  than  any  of 
these  is,  to  have  teeth  manufactured  Avith  a  plati- 
num tube  inserted,  into  which  the  pivot  can  be 
soldered.  Pivots  may  also  be  attached  to  the  ordi- 
nary plate  teeth. 

For  attaching  the  metal   pivot  to  the  root,  it  is 
sometimes  fitted  tightly  to  the  canal,  and  introduced 


METALLIC    PIVOTS.  281 

into  it  without  any  other  substance.  This  is  objec- 
tionable, on  account  of  the  wearing  of  the  root,  certain 
to  take  place,  if  there  is  the  least  jarring  or  moving 
of  the  crown.  To  obviate  this,  various  methods 
have  been  devised  ;  one  of  which  is,  to  wind  floss 
silk  about  the  pivot  before  introducing  it ;  but  this 
soon  becomes  offensive,  and  requires  very  frequently 
to  be  renewed.  An  other  method  is,  to  introduce  a 
piece  of  wood  into  the  fang,  and  drill  through  it  for 
the  reception  of  the  pivot,  which  is  squared  and 
roughened  —  squared  to  prevent  it  from  turning 
round,  and  roughened  to  secure  it  from  drawing  out. 
But  if  it  is  desirable  to  remove  the  tooth  occasion- 
ally, the  pivot  should  not  be  barbed. 

Metal  tubes  may  be  introduced  into  the  fangs  for 
the  reception  of  the  pivots.  These  tubes  are  made  of 
hollow  gold  wire  of  proper  size  ;  the  method  of  pre- 
paring which,  is,  to  take  a  piece  of  No.-30  gold  plate, 
from  four  to  six  inches  long,  and  from  a  third  to  a 
half  an  inch  wide,  and  bend  it  round  a  piece  of  smooth 
polished  steel  wire  of  the  size  of  the  intended  pivot; 
draw  both  together  through  a  clrawplate,  down  to  one 
size  larger  than  the  hole  in  the  fang  ;  then  take  out  the 
wire,  and  solder  up  the  tube  ;  on  it  cut  a  fine  thread 
with  a  screwplate  ;  from  it  cut  off  from  a  half  to  three 
fourths  of  an  inch  in  length,  and  insert  into  this  a 
piece  of  the  wire  it  was  drawn  upon  ;  grasping  this 
section  with  a  small  vice  or  pair  of  nippers,  screw  it 


282  PIVOT    TEETH. 

carefully  into  the  root ;  and,  having  introduced  it 
far  enough,  withdraw  the  piece  of  wire,  cut  off  the 
protruding  piece  of  tube  with  a  fine  saw,  and  file  and 
neatly  polish.  The  root  is  thus  ready  for  the  recep- 
tion of  the  crown,  the  pivot  of  which  should  fit  very 
accurately  into  the  tube.  A  very  slight  inflection  of 
the  pivot  will  enable  it  to  retain  a  very  firm  hold  in 
the  tube.  The  tube's  inner  end  may  be  soldered  up 
if  desirable ;  and,  if  there  is  decay  at  the  orifice  of 
the  canal,  a  flange  may  be  soldered  on  to  its  outer  end, 
flush  with  the  end  of  the  root,  and  the  decayed 
cavity  filled  beneath  it,  the  flange  serving  to  retain 
the  filling  perfectly  in  place.  These  tubes  can  be 
best  fitted  in  with  the  screw,  though  they  are  some- 
times placed  in  without  this,  and  foil  packed  about 
them  to  retain  them.  They  may  be  made  to  receive 
a  square  pivot,  by  being  drawn,  in  their  manufacture, 
on  a  square  wire,  in  stead  of  a  round  one.  For  the 
escape  of  pus,  as  already  referred  to,  the  pivot  may 
be  made  of  hollow  wire,  with  a  hole  through  the 
crown  of  the  tooth. 

A  plate  tooth,  with  a  metallic  pivot  attached,  may 
be  used  in  stead  of  the  ordinary  pivot  tooth  ;  and  it 
is  in  some  cases  required,  on  account  of  the  manner 
in  which  the  teeth  antagonize.  But  in  all  cases 
where  a  plate  tooth  is  used,  it  should  have  a  metallic 
base  to  rest  on,  and  cover  the  end  of,  the  root.  Pro- 
perly to  construct  this,   an  impression   must  be  ob- 


METALLIC    PIVOTS.  283 

tained,  and  models  and  countermodels  made,  and 
the  base  swaged ;  and  then  to  this  the  pivot  and 
tooth  are  attached.  Irregularity  of  the  teeth,  and 
especially  of  the  root  on  which  the  crown  is  to  rest, 
may  require  a  peculiar  adjustment  of  the  pivot,  which 
may  be  very  happily  effected  by  the  method  just  re- 
ferred to. 

Occasionally,  bad  consequences  follow  the  opera- 
tion of  inserting  a  pivot  tooth,  the  most  frequent  of 
which  is,  inflammation  of  the  periosteum.  Rough 
manipulation  is  very  liable  to  induce  this  condition, 
where  there  is  an  inflammatory  diathesis;  in  which 
case,  too  great  care  can  not  be  recommended  ;  and 
prior  treatment  will  sometimes  be  advantageous. 
After  periostitis  has  supervened,  either  constitutional 
or  local  treatment,  or  both,  may  be  employed  ;  con- 
stitutional, by  emetics  and  saline  cathartics,  and, 
indeed,  any  agent  that  will  equalize  the  circulation 
and  counteract  the  inflammation ;  and  local,  by  the 
same  means  as  already  prescribed  for  periostitis  else- 
where— in  addition  to  which,  it  may  sometimes  be 
necessary  to  remove  the  crown  and  pivot  from  the 
root.  It  is  always  important  to  commence  the  treat- 
ment of  such  cases  at  the  first  indications  of  the 
disease. 

Sometimes,  even  with  considerable  care,  a  crown 
will  be  split  by  the  introduction  or  the  expansion  of 
the  pivot ;  in  which  case,  of  course,  an  other  tooth 


284  PIVOT   TEETH. 

must  be  selected.  When  a  pivot  breaks  off,  and  a 
portion  adheres  in  the  fang,  this  may  be  drawn  out 
with  pliers  or  a  pivot-extractor,  or,  if  it  does  not  pro- 
trude enough  for  this,  it  may  be  drilled  out.  A  fang 
is  sometimes  split  by  the  expansion  of  a  tightly-fitting 
pivot,  or  by  a  blow  on  the  crown  of  the  tooth  ;  and 
when  this  happens,  it  must  be  removed,  since  it  can 
not  be  made  any  longer  to  retain  a  tooth.  Pivot 
teeth  should  seldom,  if  ever,  be  worn  in  a  mouth  in 
which  teeth  on  plate  are  worn.  In  any  case,  indeed, 
they  are  now  far  less  frequently  worn  than  they 
formerly  were,  because,  perhaps,  of  the  improved 
methods  of  inserting  teeth  on  plate.  Under  favor- 
able circumstances,  however,  they  may  be  worn  with 
great  comfort  and  usefulness,  from  five  to  fifteen 
years. 


CHAPTER  XI. 

EXTRACTION    OF    TEETH. 
GENERAL    REMARKS. 

The  extraction  of  teeth  is  an  important  operation, 
requiring,  for  its  proper  performance,  skill,  judgment, 
and  experience,  as  well  as  an  accurate  knowledge  of 
the  parts  to  be  acted  upon.  Success  in  the  operation 
used  to  be  very  uncertain  ;  but  now,  from  an  increase 
of  knowledge  in  the  art  of  dental  surgery,  and  from 
great  improvements  in  the  instruments  employed,  the 
operation  is  generally  attended  with  success.  The 
ancients  were  not  strangers  to  this  operation,  as  is 
evidenced  by  relics  found  in  ancient  tombs,  with 
teeth  absent,  under  such  circumstances  as  to  warrant 
the  conclusion  that  they  were  removed  by  the  sur- 
geon. Extracting  instruments  of  very  ancient  date 
have  also  been  found ;  and  ancient  writers,  too,  refer 
to  the  operation  as  one  not  much  more  pleasant  then 
than  now.  The  demand  for  this  operation  rises  not 
from  fancy,  fashion,  or  caprice,  but  from  dire  necess- 


286  EXTRACTION    OF   TEETH. 

ity — a  necessity,  too,  of  great  frequency.  Very  few 
individuals  in  this  country  arrive  at  mature  age  with- 
out being  required  to  submit  to  it ;  and,  indeed,  the 
majority,  before  middle  age,  lose  in  this  manner  from 
four  to  ten  teeth,  and  many,  all.  The  following  are 
some  of  the  objects  for  which  a  resort  is  had  to  this 
operation  : — 

1.  To  obtain  relief  from  pain,  caused  either  by 
disease  of  the  pulp,  by  inflammation  of  the  perios- 
teum, or  by  any  other  affection  involving  the  teeth, 
that  can  not  be  readily  controlled  without  their 
removal. 

2.  To  prevent  pain  in  future.  This,  of  course,  has 
reference  only  to  those  teeth  which  are  very  much 
decayed,  or  rendered  useless  by  any  cause,  and  which 
are  liable  at  any  time  to  occasion  disease  in  the  parts 
about  them. 

3.  To  save  sound  teeth  from  the  attack  and  ravage 
of  decay.  This  implies  those  teeth  which,  by  their 
offensive  condition,  would  prove  injurious  to  healthy 
teeth. 

4.  To  relieve  a  diseased  condition  of  the  contigu- 
ous parts,  such  as  alveolar  abscess,  neuralgia  excited 
by  dental  irritation,  diseased  antrum — and  some- 
times, indeed,  remote  parts,  which  are  in  many 
instances  affected  by  diseased  teeth. 

5.  To  anticipate  and  obviate  irregularity.  Of  this 
there  are  many  cases,  in  which  all  the  teeth  can  not 


GENERAL    REMARKS.  287 

be  accommodated  with  a  proper  position  in  the  arch, 
and  in  which  the  removal  of  one  or  more  of  them, 
for  this  purpose,  becomes  a  necessity. 

C.  To  prepare  the  mouth  for  a  proper  reception  of 
artificial  teeth  on  plates.  Though  plates  are  some- 
times inserted,  with  the  roots  of  teeth  remaining,  yet 
a  perfect  operation  can  never  be  effected  without 
their  removal. 

Before  anything  else  is  done,  every  case  presented 
should  be  carefully  examined,  in  order  to  ascertain 
all  the  circumstances  and  conditions  that  might  in 
any  way  affect  the  operation.  It  is  important  to 
arrive  at  a  correct  conclusion  in  regard  to  the  tooth 
or  teeth  to  be  removed ;  the  number  of  fangs,  their 
inclination,  and  the  character  of  their  attachment; 
in  what  manner,  and  to  what  extent  the  surround- 
ing parts  will  be  affected  by  their  removal ;  and  the 
probable  amount  of  force  necessary  for  this  purpose. 
The  operator  will,  in  many  instances,  be  referred  to 
the  wrong  tooth ;  for  a  sound  and  healthy  tooth  is 
sometimes  painful  from  sympathy,  and,  standing  in 
contact  with  a  decayed  and  painful  one,  makes  it 
many  times  difficult  for  the  patient  to  determine  in 
which  the  pain  exists;  and  sometimes  difficult  for  the 
operator,  too,  especially  where  the  decay  is  on  a 
proximal  portion  of  the  tooth,  and  not  easy  of 
approach.  In  all  such  cases,  great  care  should  be 
exercised,  and  a  thorough  examination  made.    There 


288  EXTBACTION    OF    TEETH. 

is  often  extensive  decay  on  the  proximal  portion  of 
the  tooth,  that  is  not  apparent  at  first  view. 

The  constitution  is  also  to  be  noted — its  peculiar- 
ities, tendencies,  and  susceptibilities;  as  these  will 
often  modify  the  operation.  A  highly  nervous  tem- 
perament will  not  endure  an  operation  that  one  of 
a  different  character  will  undergo  with  impunity. 
There  may  also  be  idiosyncrasies  and  conditions  that 
will  forbid  the  extraction  of  a  tooth.  One  of  these, 
and  not  the  least  formidable,  is  a  hemorrhagic  dia- 
thesis. 

The  manner  of  performing  the  operation  is  an 
important  consideration :  it  should  not  be  precipi- 
tate or  hurried.  A  very  good  criterion  is,  that  the 
eye  should  critically  follow,  and  the  mind  attentively 
comprehend  every  movement  of  the  hand  and  instru- 
ment. It  is  a  very  common  method,  to  seize  the 
tooth,  turn  away  or  shut  the  eyes,  and  make  the 
most  rapid  motions  possible,  regardless  of  conse- 
quences. Accidents,  such  as  breaking  of  the  tooth, 
fracturing  of  the  alveolus,  laceration  of  the  soft  parts, 
and  rupture  of  the  bloodvessels,  are  very  liable  to 
follow  such  a  hurried  execution;  and  there  are  many 
cases  on  record,  in  which  injury  has  resulted  from  a 
rapid  application  of  force  in  the  extraction  of  teeth. 
The  ancients  were  cautious  in  this  particular :  it  is 
recorded  of  them,  that  they  made  extracting  instru- 
ments of  lead,  to  prevent  injury  from  the   employ- 


GENERAL    REMARKS.  289 

ment  of  too  great  force.  It  is  difficult,  indeed, 
always  to  determine  what  amount  of  force  may  be 
necessary  for  the  removal  of  a  tooth  in  any  given 
case ;  though  by  long  and  close  observation,  it  may 
be  pretty  accurately  calculated ;  and  it  is  important 
for  the  operator  to  know  it,  so  as  to  prepare  for  the 
emergency,  and  to  select  the  instrument  appropriate 
to  the  occasion.  In  order  to  be  successful,  an  ope- 
rator must  be  confident  of  his  ability,  and,  to  be  so, 
must  be  possessed  of  it.  He  should  be  familiar  with 
the  anatomical  structure  of  the  parts  to  be  operated 
upon ;  should  understand  the  physiological  and  the 
pathological  conditions  of  the  parts  adjacent ;  and 
should  properly  appreciate  their  influence  on,  and 
their  connection  with,  the  teeth. 

There  is  a  great  difference  in  teeth  with  regard  to 
their  facility  of  removal.  Those  most  difficult  to  ex- 
tract, possess  the  following  peculiarities  :  shortness 
and  thickness  of  crown  ;  in  the  incisors,  thickness — 
the  edges  of  the  superior  and  the  inferior  meeting 
squarely  on,  or  deviating  but  little  from  their  points; 
freedom  from  prominences  on  the  crowns  of  the  mo- 
lars and  bicuspids,  their  masticating  surfaces  being 
smooth  ;  regularity  in  arrangement,  all  being  in  cor- 
rect position  and  in  contact  with  one  an  other ;  color 
slightly  yellow  ;  denseness  and  thickness  of  alveolus; 
unyielding  firmness  of  the  soft  tissues  ;  lack  of  promi- 
nences on  the  gums  to  indicate  the  size  and  position 


290  EXTRACTION    OF   TEETJI. 

of  the  fangs.     An   other  class  of  teeth,  differing  in 
characteristics  from  those  of  the  above,  are  also  very 
difficult  of  extraction,  namely :  those  having  crowns 
of  medium    length   and   of  a  diameter  at  the  neck 
much  less  than  at  the  masticating  surface  ;  fangs  long 
and    divergent,    and    in    some    cases    considerably 
curved  ;  sometimes  an  osseous  attachment,  and  often 
a   very  firm  union   with    the    alveolus,  even   where 
there  is  no    bony  attachment,  so  that  a  portion  re- 
mains adhering  to  the   tooth  when  it  is  extracted ; 
which  occurs  more  frequently  with  the  superior  cus- 
pid teeth  than  with  any  others;  and  often  the  septum 
between  the  fangs  is  so  firmly  embraced  by  them, 
especially    when    they  converge,  that   it  is  brought 
away  with  the  tooth  on  its  extraction.     Bony  union 
of  the  teeth  has  been  enumerated  as  one  of  the  occa- 
sional obstacles  in  extraction  of  the  teeth ;  but  this 
is  of  so  very  rare  occurrence — the  mode  of  develop- 
ment   almost  precluding  the  possibility  of  its  exist- 
ence— that  it  need  scarcely  be  reckoned.     Exostosis 
of  the  fang  sometimes  renders  extraction  very  diffi- 
cult, especially  when  the  enlargement  attaches  to  the 
point  of  the  fang,  and  forms  a  bulb  larger  than  the 
diameter  of  the  root  elsewhere.     It  is  then  like  a 
ball  in  a  socket,  and,  if  the  walls  of  the  alveolus  are 
thick   and   firm   and  closely  embrace  the   fang,  the 
tooth    is    very    securely   retained.     Exostosis  of  the 
same  extent  in  the  inferior  as  in  the  superior  teeth, 


GENERAL    REMARKS.  291 

will  render  the  latter  the  more  difficult  to  remove, 
because  of  the  greater  density  of  the  inferior  max- 
illa ;  and  it  has  been  maintained  that  this  cause 
would  produce  a  like  difference  even  in  the  normal 
condition  of  the  organs ;  but  experience  does  not 
warrant  the  opinion.  The  superior  molars  have 
more  numerous  and  more  divergent  fangs  than  the 
inferior  ;  and  the  fangs  of  the  anterior  superior  teeth 
are  much  larger,  and  consequently  have  a  greater 
amount  of  attachment,  than  the  anterior  inferior 
ones.  In  a  healthy  condition,  the  periosteum  of  the 
fang  has  comparatively  little  sensibility  ;  but  in  pro- 
portion as  it  is  subjected  to  acute  disease,  is  the  sensi- 
bility, and  thus  the  pain  consequent  on  the  removal 
of  the  tooth,  augmented. 

Instruments  adapted  to  all  the  different  forms  and 
locations  of  the  teeth,  are  requisite  in  the  various 
operations  of  extraction.  It  is  impossible  to  remove 
all  teeth  in  a  proper  manner  with  but  three  or  four 
instruments,  as  recommended  by  some. 

For  any  kind  of  successful  manipulation  in  the 
mouth,  and  especially  that  involved  in  the  extraction 
of  teeth,  the  patient  should  be  placed  in  such  a  posi- 
tion as  to  make  him  the  most  comfortable,  and  to 
secure  to  the  operator  the  greatest  facility  of  execu- 
tion. But  different  positions,  of  course,  will  be  re- 
quired for  the  removal  of  different  teeth.  Finally, 
there  should  be  as  little  show  of  preparation  and  as 


292  EXTRACTION    OF   TEETH. 

little  display  of  instruments  as  possible — thus  to 
avoid  exciting  the  nervous  apprehensions  of  the 
patient ;  and  the  operator  should  at  all  times  exhibit 
a  gentle  and  encouraging  deportment,  yet  work 
promptly  and  surely. 

INDICATIONS    FOR   EXTRACTION. 

The  most  common  and  imperative  indication  is, 
continued  and  violent  toothache.  In  all  cases  where 
the  teeth  are  diseased  and  painful,  and  can  not  be  re- 
stored to  health,  they  should  be  removed.  There 
are,  however,  few  cases  of  diseased  teeth,  that  cannot 
be  relieved  by  the  present  methods  of  treatment,  so 
as  to  remain  in  the  mouth  with  some  degree  of  com- 
fort and  usefulness.  Alveolar  abscess  terminating  on 
the  outside  of  the  face,  or  tending  to  it,  always  indi- 
cates the  removal  of  the  offending  tooth.  Chronic 
inflammation  of  the  investing  membrane  used  to  be 
considered  an  indication  for  extraction ;  but  it  is 
found  that  many  cases  thus  affected,  may,  by  judi- 
cious treatment,  be  restored  to  comparative  health. 
Ulceration  of  the  investing  membrane  clearly  points 
to  extraction  as  the  remedy.  Teeth  that  have  no 
antagonists,  and  that,  on  this  account,  keep  up  an  ir- 
ritable condition  in  the  contiguous  parts,  should  be 
removed  ;  and  so,  as  a  general  rule,  should  super- 
numerary teeth.     In  order  to  relieve  a  crowded  con- 


INDICATIONS   FOR    EXTRACTION.  293 

dition  of  the  teeth,  it  is  sometimes  necessary  to  re- 
move one  or  more,  even  though  they  may  be  healthy. 

Till  within  the  last  few  years,  the  existence  of  an 
alveolar  abscess  was  considered  an  indication  for  the 
removal  of  the  tooth  from  which  it  proceeded ;  but, 
under  the  present  mode  of  treatment,  except  in  very 
aggravated  cases,  a  simple  abscess  is  not  reckoned  a 
sufficient  cause  for  extraction. 

The  posterior  teeth  may  be  removed  for  causes 
that  would  not  warrant  a  removal  of  the  anterior. 
All  dead  teeth  and  roots  that  produce  or  keep  up  irri- 
tation, should  be  removed,  especially  if  the  tendency 
is  persistent. 

The  temporary  teeth  that  are  not  cast  at  or  near 
the  time  their  respective  permanent  teeth  should  ap- 
pear through  the  gum,  ought  to  be  removed  ;  but 
caution  must  always  be  exercised,  lest  they  be  re- 
moved too  soon.  Painful  and  uncontrollable  disease 
may  indicate  their  removal  long  before  the  period  just 
mentioned ;  yet  they  should  not  be  removed  on  ac- 
count of  diseased  condition,  unless  the  rudiments  of 
the  permanent  teeth  are  likely  to  suffer  thereby.  A 
crowded  condition  of  the  permanent  with  the  tempo- 
rary teeth,  may  indicate  the  removal  of  one  or  more 
of  the  latter.  It  is  important  to  understand  the  true 
indications  for  the  removal  of  temporary  teeth ;  in 
these,  as  in  the  permanent  teeth,  apparent  indications 
are  liable  to  be  mistaken  for  real  ones.     Teeth  may 


294  EXTRACTION    OF   TEETH. 

sometimes,  even  though  unclecayed,  produce  nervous 
affections,  and  in  such  a  manner  as  to  render  their 
removal  necessary.  This  indication  is  most  frequent 
with  teeth  affected  by  exostosis. 

A  high  state  of  inflammation  in  the  contiguous 
parts,  is  regarded  by  some  as  a  counter  indication; 
but  it  can  be  such  only  in  cases  in  which  the  inflam- 
mation would  be  increased  by  the  operation ;  and 
this  would  happen  only  where  there  is  a  decided 
inflammatory  diathesis;  which  peculiarity  can  be 
readily  detected  by  a  little  carefulness  of  observation. 

EXTRACTING    INSTRUMENTS. 

Numerous  and  various  instruments  have  been 
employed  for  extracting  teeth  ;  and  each  of  these 
has  passed  through  various  modifications.  Imper- 
fection and  inadaptation  have,  till  within  a  few  years, 
characterized  them  all  in  a  marked  degree,  as  indi- 
cated by  the  numerous  changes  they  have  undergone. 
Two  general  classes  comprehend  them  all  —  repre- 
sented by  the  key  and  the  forceps.  The  former 
makes  its  attachment  on  one  side  of  the  tooth, 
coming  in  contact  with  but  a  small  portion  of  it,  and 
has  a  resting  point  for  a  fulcrum  on  the  adjacent 
parts,  the  gum  and  the  alveolus.  The  latter  em- 
braces the  tooth  on  both  sides,  and  has  no  fulcrum 
resting  on  the  adjacent  parts.     There  are  other  in- 


THE    KEY.  295 

struments  somewhat  different  from  these  in  their 
application;  but  the  principle  on  which  they  operate, 
is  the  same.  For  instance,  the  elevator  has  a  point 
of  embrace  or  contact  with  the  teeth,  and  a  fulcrum 
or  resting  point,  on  the  adjacent  parts,  the  power 
being  applied  to  the  handle,  as  to  a  lever.  The 
screw  makes  its  attachment  inside  of  the  tooth, 
instead  of  outside,  like  the  forceps,  and  does  not 
touch  any  other  part. 

There  should  always  be  at  hand  a  sufficient 
number  and  variety  of  instruments  to  meet  every 
case,  however  rare  its  occurrence.  Desirabode  re- 
commends the  employment  of  but  four  instruments 
for  the  removal  of  all  the  teeth :  the  first  is  a  forceps, 
and  the  other  three  are  nothing  more  than  so  many 
different  forms  of  the  elevator.  He  was  not  familiar 
with  the  present  improvements  in  extracting  instru- 
ments, or  he  could  not  have  made  such  a  recom- 
mendation. 

THE    KEY. 

The  principle  of  this  instrument  was,  at  a  very 
early  period,  brought  into  requisition  for  the  extrac- 
tion of  teeth;  it  is,  emphatically,  an  old  instrument. 
It  consists  of  a  shaft  six  inches  long,  with  a  handle 
four  inches,  attached  at  right  angles,  while  the  hook 
is  attached  laterally  at  the  other  end  of  the  shaft, 
and  the  bolster,  either  movable  or  fixed,  to  the  side 


296  EXTRACTION    OF    TEETH. 

of  it,  immediately  below  the  articulation  of  the  hook. 
This  instrument  has  passed  through  a  great  variety  of 
forms  and  modifications ;  having  the  shaft  straight, 
curved,  double-curved ;  the  fulcrum  large,  small,  flat, 
round,  long,  short,  fixed,  movable,  and  anterior,  pos- 
terior, or  opposite  to  the  point  of  the  hook.  There 
has  also  been  a  great  variety  of  forms  of  the  hook; 
and  it  has  been  made  with  machinery  attached,  to 
control  its  grasp,  the  object  of  which  is,  to  prevent 
the  instrument  from  slipping  off  the  tooth,  and  skill 
in  the  use  of  which  would  doubtless  add  to  the  effi- 
ciency of  the  instrument.  The  principle  of  the 
forceps,  too,  has  been  combined  with  the  key,  and 
probably  with  very  decided  advantage. 

The  modus  operandi  of  the  key  is  worthy  of  some 
consideration.  The  hook  is  attached  to  the  shaft 
directly  above  the  bolster,  and  starts  off  at  right 
angles  with  its  vertical  axis,  but  curves  down  to  the 
point,  almost  or  quite  as  low  as  the  base  of  the  bolster. 
When  properly  constructed,  the  hook  embraces  the 
tooth  at  the  neck  on  one  side,  and  the  bolster  rests  a 
little  below  this  on  the  other.  When  the  instrument 
is  applied  to  a  tooth,  the  center  of  the  shaft  is  the 
axis  of  motion  ;  but,  as  force  is  applied  to  the  instru- 
ment, this  axis  is  transferred  from  the  shaft  to  the 
base  of  the  bolster,  which  is  the  center  of  motion  the 
moment  it  is  fixed  on  the  gum  and  alveolus,  and  the 
shaft  describes  an  arc  about  it.     Now,  as  a  result  of 


THE    KEY.  297 

this  motion  and  arrangement,  the  line  of  force  is  at 
an  angle  of  from  forty  to  sixty  degrees  with  the  axis 
of  the  tooth  ;  and  hence  it  is  at  this  angle  that  the 
tooth  must  be  extracted,  if  at  all.  The  axis  of  power 
exerted  on  the  tooth  by  the  instrument,  is  in  a  line 
from  the  point  of  the  hook  to  its  attachment  to  the 
shaft ;  and  the  line  of  this  force  has  its  termination 
below  the  neck  of  the  tooth  on  one  side,  and  just 
above  the  crown  on  the  opposite  side.  The  angle 
formed  by  the  line  of  power  with  the  axis  of  the 
tooth,  is  different  in  the  different  relative  positions  of 
the  key  to  the  tooth.  If  the  instrument  is  applied  to 
an  inferior  molar,  with  the  bolster  on  the  inside,  the 
angle  of  the  line  of  force  with  the  axis  of  the  tooth  is 
about  forty  degrees ;  but,  if  placed  on  the  outside  of 
the  jaw,  as  recommended  by  some,  the  angle  con- 
tained by  the  line  of  power  and  the  axis  of  the  tooth, 
is  sixty  degrees  or  more.  The  line  of  force  is  not 
changed  by  any  form  the  hook  may  assume  ; — it  may 
be  regularly  or  irregularly  curved,  or  be  turned  at 
right  angles,  and  yet  the  line  of  force  not  be  changed 
at  all.  Indeed,  this  line  can  not  be  changed,  except 
by  changing  the  relative  position  of  the  hook  and  its 
attachment.  This  application  of  the  power  constitutes 
one  of  the  prominent  objections  to  the  use  of  the  in- 
strument :  the  force  is  applied  at  too  great  an  angle 
with  the  axis  of  the  tooth,  and  hence,  in  numerous  in- 
stances, this  is  broken  off.   The  bolster  of  the  key  rests, 


298  EXTRACTION    OF    TEETH. 

in  the  operation,  on  the  gum,  on  which  it  exerts  great 
pressure,  and  which  it  always  bruises,  and  frequently 
lacerates  in  a  cruel  manner;  and  the  degrees  of  press- 
ure exerted  by  the  bolsters  of  the  variously  con- 
structed keys  differ  but  little  ;  though,  perhaps,  the 
bolster  which  has  a  broad  base,  and  which  is  attached 
to  the  shaft  by  a  joint,  would  cause  less  pain  to  the 
patient  by  its  pressure,  and  be  much  less  liable  to 
lacerate  or  cut  the  gum,  than  the  small  and  perma- 
nent one.  The  pressure  of  the  bolster  on  the  gum 
and  process  is  always  greater  than  the  power  required 
to  extract  a  tooth  ;  and  this  extreme  pressure  and  its 
consequences  constitute  an  other  strong  objection  to 
the  use  of  this  instrument.  The  power  being  applied 
at  a  disadvantage,  much  more  of  it  is  required  than 
when  economically  applied. 

This  instrument  is  so  seldom  employed  for  the 
extraction  of  teeth,  that  any  very  special  directions 
as  to  its  use  will  scarcely  be  required ;  yet  a  few  lead- 
ing suggestions  may  not  be  out  of  place.  Whether 
a  tooth  should  be  drawn  inward  or  outward  depends 
on  its  position  and  inclination.  As  a  general  rule  for 
the  removal  of  the  molars,  the  bolster  should  be 
placed  on  the  inside  of  the  inferior  teeth,  and  on  the 
outside  of  the  superior.  For  removing  the  lower  teeth 
of  the  left  side,  the  operator  should  stand  at  the  right 
of  the  patient ;  and  for  the  teeth  of  the  right  side,  in 
front  or  at  the  right.     For  the  inferior  teeth  of  the 


FORCEPS.  299 

right  side,  he  should  stand  at  the  right  of  the  patient; 
and  for  the  left  superior,  in  front  of  him.  There  have 
been  a  great  many  different  opinions  as  to  the  manner 
of  applying  and  using  the  instrument.  One  recom- 
mends that  "  the  teeth  should  be  always  turned 
towards  the  tongue."  An  other,  "  that  the  fulcrum 
should  be  so  placed  that  it  would  not  come  in  contact 
with  the  tooth."  An  other  directs  :  "  Place  the  ful- 
crum on  the  margin  of  the  gum."  An  other  :  "  Place 
the  fulcrum  on  the  gum  below  its  margin."  An  other 
suggests,  "  that  the  fulcrum  be  placed  on  the  side  of 
the  tooth  opposite  the  point  of  the  hook."  Again, 
we  are  directed  "  that  the  tooth  should  be  drawn 
from  the  higher  alveolus."  This  great  diversity  of 
opinion  as  to  the  manner  of  using  the  key,  as  well  as 
the  great  variety  of  changes  in  its  form,  is  evidence 
that  it  is,  at  best,  a  very  imperfect  instrument.  It  is 
impossible  to  embrace  a  tooth  as  deep  with  it  as  with 
well-constructed  forceps ;  and  with  it,  the  chances  of 
accident  in  the  extraction  of  teeth,  are  much  greater 
than  with  any  other  instrument.  A  strong  advocate 
of  this  instrument  says  that  "the  key  always  produces 
injury;  but  the  greatest  skill  exhibits  the  least 
injury." 

FORCEPS. 

The  forceps  are  the  most  efficient  extracting  instru- 
ment in  use ;  and  the  improvements  made  in  them 


300  EXTRACTION    OF    TEETH. 

during  the  last  few  years  have  been  very  great ; 
indeed,  twenty  years  ago,  they  were  not  made  with 
any  special  adaptation  whatever,  and  were  totally 
unfit  to  be  used  for  the  extraction  of  teeth ;  but  now, 
they  are  constructed  with  such  various  shapes  and 
curves  as  to  facilitate  their  approach  to  teeth  having 
any  position  in  the  mouth,  and  to  fit  all  the  forms  of 
the  points,  and  make  the  most  perfect  embrace  of  the 
tooth  possible.  Forceps,  with  the  present  improve- 
ments, take  a  deeper  and  more  thorough  hold  on  the 
teeth  than  any  other  instrument.  The  beaks  may 
be  made  so  thin  that  they  will  penetrate  between  the 
fangs  and  alveolus,  and  the  adaptation  so  complete 
that  the  instrument  will  not  slip  its  hold  on  the  tooth 
at  all.  The  form  of  the  beaks  should  be  such  as  to 
fit  the  crown  without  pressing  on  it,  and  yet  perfectly 
embrace  the  neck  of  the  tooth ;  and  the  entire  instru- 
ment of  such  form  and  curve  as  to  give  to  the  hand, 
arm,  and  body  of  the  operator  the  best  position  for 
ease  and  facility  of  execution. 

There  are  various  opinions  as  to  the  position  rela- 
tive to  the  patient  which  the  operator  should  occupy 
while  extracting  teeth  with  the  forceps.  Some  re- 
commend different  positions  for  the  removal  of  differ- 
ent teeth ;  but  it  is  preferable,  on  many  accounts,  to 
occupy  as  nearly  as  possible  the  same  position  in  the 
removal  of  all ;  and  this  is  at  the  right  and  a  little 
back  of  the  patient. 


FORCEPS. 


301 


The  forceps  for  removing  the  superior  incisors  are 
straight,  and  have  thin  beaks,  which  are  sufficiently 
broad  to  embrace  the  anterior  and  the  posterior  sur- 
faces of  the  teeth  entire  (Fig.  39)  ;  and  they  should 
be  much  broader  for  the  centrals  than  for  the  laterals. 

Fie.  39. 


The  points  should  not  be  so  broad,  however,  as  to 
come  in  contact  with  the  contiguous  teeth  in  the 
rotary  motion  made  to  break  up  the  attachment. 
The  same  principle  in  regard  to  the  width  of  the  for- 
ceps is  to  be  observed  for  the  lateral  incisors  and 
cuspids.  The  ordinary  straight  root  forceps  may  be 
employed  for  the  extraction  of  the  lateral  incisors ; 
though,  for  this  purpose,  it  is  desirable  that  their 
beaks  be  somewhat  thinner  than  usual.  For  the 
superior  cuspid  teeth,  the  ordinary  bicuspid  forceps 
are  frequently  used ;  but  their  beaks  are  commonly 
too  narrow,  and  those  of  the  central-incisor  forceps 
too  thin.  The  cuspid  forceps  should  be  about  as 
wide  as  those  for  the  central  incisors,  with  the  thick- 
ness of  the   bicuspid  forceps  (Fig.  40),  and  with  a 


302 


EXTRACTION    OF    TEETH. 


greater  concavity,  so  as  to  fit  the  neck  of  the  tooth. 
Superior  bicuspid  forceps  have    narrow,   thick,   and 


Fig.  40. 


quite  concave  beaks,  and  the  instrument  is  straight, 
or  nearly  straight ;  though  for  the  second  bicuspids, 
especially  in  a  small  mouth,  it  should  have  some 
anterior  curvature.  (Fig.  41.)  One  pair  of  forceps 
will  serve  for    both    sides,  though  it  is  desirable  to 


Fis.  41. 


have  one  for  the  first,  and  an  other  for  the  second 
bicuspid.  For  the  removal  of  the  bicuspids,  there  is 
a  kind  of  forceps  with  thick,  smooth  beaks,  and  of 
such  a  form  as,  by  pressure,  to  force  the  tooth  from 
its  socket,  taking  advantage,  for  this  purpose,  of  the 
conical  form  of  the  root.     The  superior   molar  for- 


FORCEPS. 


303 


ceps,  a  pair  for  each  side,  have  one  of  the  beaks  a 
single  concave,  to  embrace  the  palatine  fang,  and  the 
other  a  double  concave,  with  a  projecting  point  from 
the  center  of  the  beak,  to  pass  into  the  bifurcation, 
and  with  the  edge  of  the  beak  so  formed  as  to  em- 
brace the  two  palatine  fangs.  The  concavity  and 
curvature  of  the  beaks  should  be  first  just  sufficient 
to  accommodate  the  crown  of  the  tooth.  These  for- 
ceps should  have  a  double  curve,  to  facilitate  their 
approach  to  the  teeth — an  anterior  curve  just  above 
the  joint,  and  a  downward  curve  just  below  it; 
sometimes,    also,    a   lateral    curve    above    the  joint, 

Fur.  42. 


throwing  the  instrument  more  toward  the  angle  of 
the  mouth.      (Fig.  42.) 

For  the  second  molars,  the  forceps  should  have  a 


304 


EXTRACTION    OP   TEETH. 


little  more  curve  above  the  joint,  than  for  the  first. 
A  third  pair  of  forceps  for  these  teeth,  and  especially 
for  the  roots  before  they  are  separated,  have  the  inner 
beak  similar  to  the  one  above,  and  the  outer  a 
curved,  attenuated,  sharp  point,  to  pass  between  the 
buccal  fangs  (Fig.  43).     The  forceps  for  the  superior 

Fig.  43. 


dens  sapiential  have  two  single-concave  beaks,  made 
to  embrace  the  tooth,  as  though  it  were  cylindrical, 
or  nearly  so,  at  its  neck.  The  instrument  has  two 
curves,  or  rather  angles,  the  one  forward,  and  the 
other  downward,  so  that  its  handle  is  somewhat  an- 
terior to,  but  almost  parallel  with,  the  axis  of  the 
tooth.     (Fig.  44.)     It  is  a  principle  that  should  be 


FORCEPS. 


305 


'bserved  in  all  forceps,  that  the  handle  be  as  nearly 
mrallel  with  the  axis  of  the  tooth  as  possible,  and  as 


Fie.  44. 


nearly  in  a  line  with  it  as  the  location  of  the  tooth, 
the  size  of  the  mouth,  and  other  circumstances  will 
admit. 

The  forceps  for  the  inferior  incisors  may  have 
either  a  lateral  or  a  transverse  curve — almost  to  a 
right  angle,  if  transverse,   but  if  lateral,   not  more 

Fisr.  45. 


than    half  that  inclination.    (Fig.  45.)       The    ordi- 
nary, slightly  curved  root  forceps  may  be  used  for 


306 


EXTRACTION    OF   TEETH. 


the    extraction   of    these   teeth.      (Fig.    46.)      The 
beaks  should  be  very  narrow  and  thin ;  for  a  great 


Fig.  46. 


amount  of  force  is  not  required  for  the  extraction  of 
these  teeth.  The  beaks  of  the  inferior-incisor  for- 
ceps should  be  relatively  broader  than  those  of  the 
forceps  for  the  superior  incisors.  Rotary  motion  in 
the  extraction  of  inferior  incisors,  is  not  admissible. 


-^€^ 


mum 


\[  it * 


The  inferior-bicuspid  forceps  are  well  adapted  to  the 
removal  of  the  cuspids  also.     These  forceps,  two  in 


FORCEPS. 


307 


number,  one  for  each  side,  are  of  different  forms. 
(Fig.  47.)  The  beaks  are  narrow,  thick,  and  quite 
concave.  The  instrument  for  the  right  side  has  a 
lateral  curvature,  which  brings  the  handle  out  at  the 
angle  of  the  mouth,  and  is  necessary  in  order  to  ob- 
viate a  contact  with  the  superior  teeth.  The  forceps 
for  the  left  side  have  beaks  of  the  same  form.  They 
are  bent  to  almost  a  right  angle  above  the  joint, 
while  below  it  the  handle  is  thrown  upward  ;  and 
their  inner  beak  is  longer  than  the  outer.  The  infe- 
rior-molar forceps    are  two  in  number,  that  for  the 

Fisr.  48. 


right  side  being  curved  outward  and  forward,  and 
that  for  the  left  forward  and  upward,  the  beak  making 
almost   a  right  angle  with  the  body  of  the  instru- 


308  EXTRACTION    OF   TEETH. 

ment,  and  the  inner  beak  of  each  being  longer  than 
the  outer.  The  beak  should  be  of  sufficient  breadth 
to  embrace  the  entire  side  of  the  tooth,  of  double- 
concave  form,  with  a  ridge  and  a  long  point  in  the 
center  of  the  beak,  to  pass  into  the  bifurcation  of  the 
fangs.  The  inner  beak  of  these  forceps  should  be 
longer  than  the  outer  ;  for  the  teeth  on  which  they  are 
designed  to  operate,  have  an  inward  inclination,  and 
the  outer  alveolus  is  higher  than  the  inner.  (Fig. 
48.) 

A  pair  of  forceps  for  the  left  side,  similar  in  form 
to  those  for  the  right,  would  be  preferable  to  the 
ordinary  left  forceps,  when  the  mouth  can  be  opened 
wide  ;  and  the  curvature  of  the  handle  of  this  instru- 
ment would  be  toward  the  center  of  the  mouth,  in- 
stead of  outward,  as  that  of  the  right  forceps.  With 
this  form  of  forceps,  more  power  can  be  exerted  than 
with  the  ordinary  left  inferior  forceps. 

Forceps  for  the  removal  of  the  inferior  dens  sapi- 
enike  have    large    single-concave    beaks,  to   make   a 

Fi<r.  49. 


general   embrace  of  the    tooth,  and    have   but   one 
curve,  which  is  between  the  joint  and  the  point,  and  is 


FORCEPS.  309 

almost  a  right  angle.  (Fig.  49.)  One  pair  of  forceps  of 
this  kind  is  quite  sufficient  for  both  the  right  and  the 
left  side.  The  forceps  denominated  Physics  forceps 
are  also  sometimes  employed  for  the  removal  of  the 
wisdom-teeth.  These  are  constructed  with  thick, 
sharp  blades,  the  edges  of  which  come  squarely 
together,  and  the  points  sometimes  have  an  enlarge- 
ment on  them.  They  are  curved  almost  to  a  right 
angle :  without  this  curve,  the  edges  would  be 
parallel  with  the  handle.  (Fig.  50.)  There  are  two 
or  three  different  forms  of  Physic's  forceps. 

Fi<r.  50. 


Of  the  considerable  variety  of  root  forceps  now  used, 
those  for  the  removal  of  the  anterior  teeth,  are 
straight,  or  but  slightly  curved,  with  long,  thin, 
sharp-edged  beaks,  and  of  a  width  regulated  by  the 
size  of  the  roots.  Those  for  the  removal  of  the  roots 
of  the  superior  molars,  when  these  are  separated, 
have  the  same  form  of  beaks  as  those  for  the  front 
teeth,  but  more  curved,  to  facilitate  their  approach  to 
the  roots.  For  the  removal  of  these  roots,  it  is  well 
to  have  several  pairs  of  forceps  with  different  degrees 


310 


EXTRACTION    OF   TEETH. 


of  curvature,  using,  in  any  given  case,  those  with  the 
least  admissible  curve — which,  in  a  small  mouth, 
will  be  considerable,  while  in  a  large  one,  it  will  be 
very  slight.  The  same  forceps  that  are  used  for  the 
removal  of  the  front  inferior  teeth,  are  applicable  to 
the  removal  of  their  roots. 

Of  the  different  forms  of  forceps  for  the  removal  of 
the  roots  of  inferior  molars,  those  for  the  extraction 
of  the  roots  before  they  are  separated,  and  while  they 
are  firmly  attached,  have  two  long,  slender,  round, 
curved  beaks,  designed  to  pass  down  deep  between 
the  two  roots;  their  curvature  should  be  almost  a 
right  angle,  and  their   handles  assume  the  form  of 

Fi<r.  51. 


the  ordinary  right    and   left    inferior-molar  forceps, 
already  described  (Fig.  51)  ;  or,  if  but  one  is  used, 


ELEVATORS. 


311 


the  handle  should  be  straight.  The  forceps  for  the 
removal  of  these  roots  after  they  are  separated, 
should  have  the  beaks  of  the  same  form  as  those  of 
the  superior-root  forceps ;  but  the  beaks  should  be 
curved  to  a  right  angle  with  the  handle,  and  the 
handle  be  straight.     (Fig.  52.) 


ELEVATORS. 

There  are  in  use  variously  formed  instruments 
constructed  on  the  principle  of  the  elevator.  They 
are  made  with  such  points  as  to  take  the  most  tho- 
rough hold  on  the  teeth  or  roots  on  which  they  are 
to  be  used,  and  with  such  curvature  of  shaft  as  to 
enable  them  to  pass  most  readily  to  the  desired  posi- 

Fiff.  53. 


tion.     Some  are  so  formed  at  the  points   as  to  em- 
brace the  root  at  the  border  of  the  alveolus,  using; 


312 


EXTRACTION    OF    TEETH. 


the  latter  as  a  fulcrum  (Fig.  53) ;  others,  to  pass 
between  the  alveolus  and  the  root  (Fig.  54)  ;  others, 
to  cut  through  the  alveolus,  and  thus  approach  the 


Fisr.  54. 


root.  All  the  ordinary  elevators  make  a  fulcrum  of 
the  alveolus  or  of  an  adjoining  tooth;  but  some  ope- 
rators, in  using  this  instrument,  contrive  to  make  a 
fulcrum  of  the  thumb  or  one  of  the  fingers ;  which 
is  the  preferable  way. 


HOOKS. 


These  are  formed  so  that  the  point  shall  embrace 
the  root  and  remove  it,  without  any  rest  on  the  sur- 
rounding parts.      The    root   is    removed    simply   by 


Fig.  55. 


pressure,  applied  in  the  proper  direction.      Of  the 
various  forms  of  this  instrument,  there  are  the  for- 


SCREW. 


313 


ward  hook,  the  backward   (Fig.  55),  and  the   com- 
pound (Fig.  50),  which  last  includes  the  former  two. 


Fig.  5G. 


These  are  valuable  instruments,  but  require  care  in 
order  to  avoid  injuring  the  surrounding  parts. 


SCREW 


This  is  a  cone-shaped  instrument,  with  a  very 
definite,  sharp  screw-thread  on  it ;  and  the  manner 
of  using  it  in  the  operation  of  extraction  is,  to  screw 
it  into  the  fang.  It  will  be  required  to  be  of  various 
sizes  to  correspond  with  those  of  the  different  roots 
to  be  extracted.  It  is  commonly  attached  to  the 
handle  by  a  permanent  shaft  (Fig.  57)  ;  but,  some- 


Pii 


times,  it  is  made  with  a  square  shaft  fitted  into  a 
socket  handle   (Fig.  5S),  by  which  arrangement  the 


314 


EXTRACTION    OF    TEETH. 


handle  is  used  only  to  introduce  the  screw  ;  and  this 
serves  only  as   a  support  to  a  frail  root,  the  forceps 

Fig.  58. 


being  then  brought  to  bear,  in  connection  with  it,  for 
the  removal  of  the  fang.  A  screw-top,  of  the  same 
form  as  the  screw,  should  accompany  it. 

When  the  screw  is  combined  with  the  forceps,  for 
the  purpose  of  supporting  the  root  and  preventing 
it  from  crushing  while  it  is  removed  with  the  forceps, 
the  latter  is  of  the  same  form  as  that  of  the  ordinary 
straight-root  forceps,  with  the  shaft  of  the  screw  at- 
tached in  the  joint.  In  some,  the  screw  is  attached 
with  a  spring  and  ratchet,  so  that  it  can  be  drawn 
out,  seized  between  the  beaks,  and  introduced  into 

Fi<r.  59. 


the  root ;  and  then  these  are  slipped  on  the  root, 
which  they  embrace  and  remove.  In  others,  the 
screw  is  fixed  ;  but  the  movable  screw  is  to  be  pre- 


GUM-LANCET.  315 

ferred.  (Fig.  59.)  An  arm  bearing  a  pad,  to  rest  as 
a  fulcrum  on  the  other  teeth,  is  sometimes  attached 
to  the  shaft  of  the  screw  ;  but  this  is  objectionable 
because  of  its  liability  to  impede  the  action  of  the  in- 
strument, and  also  to  injure  the  adjoining  teeth. 

GUM-LANCET. 

Of  the  various  forms  of  the  gum-lancet,  the  most 
common  is  that  with  the  round  point,  and  with  the 
blade  from  two  to  four  lines  wide,  and  from  half  an 
inch  to  an  inch  long,  attached  to  a  shaft  and  handle  ; 
the  whole  being  about  six  inches  in  length.  The  in- 
strument should  have  a  keen  edge  on  the  sides,  two 
or  three  lines  from  the  extreme  point.  It  is  some- 
times made  with  the  edge  square  ;  but  the  round 
edge  is  the  better  form.  The  edge  is  parallel  with 
the  handle  in  the  ordinary  lancet.  (Fig.   60.)     This 

Fig.  GO. 


form  is  used  for  separating  the  gum  from  the  buccal 
and  palatal  surfaces  of  the  tooth.  A  lancet  with  the 
edge  transverse  to  the  shaft  is  required  for  separating 
the  gum  from  the  proximal  portions  of  the  teeth. 
The    blade   of  this  should  be  of  the  same  general 


316 


EXTRACTION    OF    TEETH. 


form  as  that  already  described,  except  that  it  should 
be  quite  narrow — in  no  case  more  than  two  lines 
wide.   (Fig.   61.)      Gum-lancets    are    made    with   the 


Finr.   Gl. 


blade  set  in  a  socket  on  the  end  of  the  shaft,  so  that 
it  can  be  rotated  and  set  to  any  angle,  to  meet  every 
case. 

A  very  ingenious  instrument,  invented  by  Dr. 
Merry,  and  denominated  "  Merry's  Revolving  Gum- 
lancet."  has  recently  been  brought  to  the  notice  of 
the  profession.  This  is  a  very  excellent  instrument 
— superior,  indeed,  to  any  thing  else  of  the  kind. 
(Fig.  62.)  The  following  is  a  description  of  it :  "  It 
consists    mainly   of  two   shafts  :    one   is   round  and 

Fi".  G2. 


small ;  the  other  is  larger,  and  part  round,  and  part 
octagon.  Just  back  of  the  spiral  spring  which  curves 
down  at  the  lancet  end,  is  seen  a  piece  connecting 


METHOD    OF    LANCING   THE    GUMS.  317 

the  two  shafts.  This  piece  is  soldered  fast  to  the 
round  shaft,  while  the  upper  end  of  it  forms  a  collar, 
in  which  the  round  part  of  the  larger  shaft  slides 
back  and  forth,  and  revolves.  On  the  other  end  of 
the  large  shaft  is  seen  a  screw,  made  by  winding  a 
wire  spirally  round  it.  This  is  the  male  screw. 
From  the  small  shaft  rises  an  other,  but  shorter 
spiral  wire,  which,  it  will  be  seen,  fits  in  the  male 
screw.  The  short  one  may  be  considered  the  female, 
or  nut,  in  which  the  other  revolves.  The  ends  of 
the  short  spiral  are  soldered  fast  to  the  small  shaft. 
If,  then,  the  large  shaft  is  revolved,  the  screw  on  it 
playing  in  the  female,  is  made  to  slide  back  and 
forth,  accordingly  as  it  may  be  revolved.  This 
motion,  then,  changes  the  direction  of  the  point  of 
the  lancet  to  the  plane  of  the  shafts,  any  degree  from 
a  right  angle  to  a  parallel.  Having  thus  got  the  in- 
clination which  is  desired,  the  blade  is  inserted  into 
the  gum  at  the  point  at  which  the  incision  is  to 
begin  ;  and  as  the  instrument  cuts,  rotate  the  larger 
shaft  slightly,  and  the  blade  will  follow  the  outline 
of  the  tooth  as  it  cuts  round  it." 


THE    METHOD    OF    LANCING    THE    GUMS. 

In  all  cases,  the  gum  should  be  separated  from  the 
tooth  as  far  as  the  embrace  of  the  forceps  is  to  ex- 
tend ;  and  the  lancet  should  pass  close  to  the  tooth, 


818  EXTRACTION    OF   TEETH. 

so  as  to  make  the  separation  clean  about  its  neck  ; — 
in  order  to  which,  the  lancet  must  be  kept  in  good 
condition ; — and  it  should  also  be  passed  freely 
between  the  teeth.  A  complete  separation  of  the 
gum  is  essential  to  a  good  hold  of  the  forceps  on  the 
tooth.  Some  operators,  however,  do  not  use  the 
lancet  for  this  purpose,  but  tear  the  gum  away  by 
forcing  the  forceps  to  its  position  on  the  tooth.  This 
method  is  objectionable  on  several  accounts:  it  causes 
the  patient  much  more  pain  than  with  a  sharp 
lancet;  the  forceps  can  not  thus  be  adjusted  to  the 
tooth  with  so  much  facility ;  there  is  far  more  danger 
of  lacerating  the  soft  parts,  and,  because  of  an  imper- 
fect, adaptation  of  the  forceps  to  the  tooth,  more 
danger  of  fracturing  this;  and  the  operation  is  always 
more  difficult  of  accomplishment.  In  those  cases  in 
which  the  gum  is  firm  and  tense,  and  would  obstruct 
the  free  passage  of  the  forceps  to  the  proper  position 
on  the  tooth,  it  is  sometimes  necessary  to  make  a 
vertical  incision  of  the  gum,  even  after  it  has  been 
separated,  directly  opposite  the  fang.  But  it  is  in 
many  instances  better  to  cut  away  a  portion  of  the 
free  margin  of  the  gum,  in  the  extraction  of  roots 
that  are  partially  covered  by  it;  and  there  is  no 
objection  to  this  method  in  any  case  where  it  may 
at  all  facilitate  the  operation ;  for  this  portion  of  the 
gum,  if  let  remain,  is  always  absorbed  away  after  the 
extraction  of  teeth.     It  is  also  sometimes  necessary 


EXTRACTION    OF   TEETH.  319 

to  dissect  the  gum  somewhat  from  the  alveolus  in 
those  cases  in  which  a  deep  hold  on  the  tooth  or  root 
is  required,  and  in  which  the  alveolus  is  either  cut 
away  or  embraced  by  the  forceps.  The  character 
and  condition  of  the  tooth  will  somewhat  modify  the 
extent  to  which  the  gum-lancet  should  be  used. 


EXTRACTION    OF    THE    TEETH. 

In  the  following  remarks,  it  is  the  design  to  con- 
sider only  those  principles  obviously  involved  in  the 
extraction  of  the  teeth  with  forceps,  and  in  the  ex- 
traction of  roots  with  forceps,  elevators,  and  screws. 

Superior  Incisors. — After  an  examination,  the  gum, 
as  in  all  cases,  should  be  perfectly  separated  from  the 
neck  of  the  tooth,  up  to  the  border  of  the  alveolus  : 
this  is  quite  sufficient,  if  the  tooth  is  not  too  much 
decayed.  With  the  forceps  already  described  (see 
Fig.  39),  grasp  the  tooth  firmly  at  the  border  of  the 
alveolus;  introduce  the  instrument  slowly,  adjusting 
it  carefully,  as  it  passes  up  to  the  proper  position  ; 
then,  by  a  gradual  movement,  rotate  the  tooth  in  the 
socket,  thus  breaking  up  the  attachment.  All  the 
cylindrical,  single-fang  teeth  may  be  luxated  by  a 
rotary  motion.  There  are  occasional  circumstances, 
however,  that  render  this  somewhat  difficult, — as,  for 
instance,  any  considerable  curvature  of  the  root;  or, 
sometimes,  the  attachment  to  the  outer  plate  of  the 


320  EXTRACTION    OF   TEETH. 

alveolus  is  so  firm  that  it  can  not  be  broken  up  by 
rotary  motion.  Neither  of  these  difficulties  is  usual 
with  the  lateral  incisors ;  but,  with  the  centrals,  one 
or  other  of  them  is  not  unfrequent.  When  either  of 
them  does  occur,  the  attachment  must  be  broken  up 
by  an  inward  and  outward  movement,  which,  on 
account  of  the  pressure  made  on  the  parts,  is 
attended  with  much  more  pain,  and  far  greater 
danger  to  the  contiguous  parts,  than  the  loosening 
by  rotary  motion. 

The  roots  of  the  incisors  are  not  difficult  to  remove, 
unless,  being  very  much  decayed,  they  will  not  sus- 
tain the  embrace  of  the  forceps  below  the  border  of 
the  alveolus ;  and  when  they  are  thus  decayed,  one 
of  the  following  methods  may  be  adopted :  the  gum 
may  be  dissected  on  the  alveolus,  and  the  latter  cut 
away  with  the  thick  cutting  instrument,  so  as  to 
expose  the  root  sufficiently  for  extraction  with  the 
root  forceps ;  or,  after  the  gum  is  dissected  up,  the 
alveolus  and  the  root  may  be  together  embraced,  and 
the  former  broken  away  with  the  latter.  This  is  a 
rather  rough  method  of  operation,  though  it  is  often 
adopted.  Or,  an  elevator  of  the  proper  form  may  be 
introduced  between  the  root  and  the  alveolus,  and 
the  root  thus  dislodged. 

The  screw,  either  simple  or  compound,  is  a  valuable 
instrument  for  the  removal  of  these  roots.  But  the 
gum  should  be  separated  even  when  the  extraction 


EXTRACTION    OF   TEETH.  321 

is  to  be  accomplished  with  this.  The  canal  in  the 
root  should  first  be-  enlarged  with  a  taper  drill,  of  the 
same  shape  as  the  screw,  till  all  the  softened  dentine 
is  removed.  Then  the  screw,  selected  of  proper  size, 
and  with  a  very  sharp  and  firm  thread,  is  introduced 
till  it  takes  a  strong  hold  in  the  solid  dentine,  espe- 
cially if  it  is  the  simple  screw.  In  some  instances, 
while  it  is  being  introduced,  the  root  will  be  loosened. 
In  using  the  screw  in  connection  with  the  forceps,  it 
is  not  necessary  to  introduce  it  with  the  same  firm- 
ness as  when  the  screw  alone  is  employed.  In  the 
use  of  the  screw-forceps,  the  screw  is  embraced  in 
the  beaks,  and  introduced ;  then,  the  forceps  are 
passed  up  on  the  root,  or  between  it  and  the  alve- 
olus, if  need  be,  the  screw  serving  to  sustain  the  root 
under  the  pressure  of  the  forceps.  The  attachment 
of  the  root  is  broken  by  a  rotary,  or  an  inward  and 
outward  movement,  as  the  case  may  require. 

Superior  Cuspids. — For  the  removal  of  these  teeth, 
the  central-incisor  or  the  bicuspid  forceps  may  be 
used ;  though  usually,  the  beaks  of  the  former  are  too 
thin,  and  those  of  the  latter,  too  narrow.  The  for- 
ceps appropriate  for  the  removal  of  these  teeth,  have 
broad,  deep,  concave  beaks,  so  as  to  embrace  the  tooth 
as  completely  as  possible ;  and  'they  are  thick,  so  as 
to  possess  sufficient  strength.  The  gum  being  sepa- 
rated, and  the  forceps  adjusted  on  the  tooth,  the  at- 
tachment is  broken  up,  either- by  an  inward  and  out- 


322  EXTRACTION    OF   TEETH. 

ward,  or  by  a  rotary  movement ;  the  former  will  be 
far  more  frequently  brought  into  requisition,  since 
these  teeth  are  generally  so  firmly  attached  that 
they  can  not  be  loosened  by  the  latter ;  but  the  skill- 
ful and  experienced  operator  will  often  combine  the 
two,  with  the  happiest  effect.  These  teeth  have 
larger  roots  than  any  others  in  the  mouth,  and  the 
alveolar  process  closely  invests  them ;  and  thus  they 
are  very  firmly  fixed  in  the  sockets,  and  are  also 
more  frequently  found  curved  than  the  roots  of  the 
incisors.  Often,  in  extraction  of  the  cuspids,  a  por- 
tion of  the  outer  wall  of  the  alveolus  is  broken  off, 
and  comes  away  with  the  tooth.  But  this  accident 
is  not  attended  with  any  serious  results ;  indeed,  in 
the  preparation  of  the  mouth  for  artificial  teeth,  it  is 
desirable  that  it  be  broken  away. 

The  movement  in  the  extraction  of  a  tooth  should 
always  be  very  deliberate — never  sudden  and  violent. 
A  very  good  criterion  in  regard  to  the  rapidity  of 
movement,  is,  that  the  eye  should  follow  and  dis- 
tinctly recognize  every  motion  of  the  forceps,  the 
tooth,  and  the  contiguous  parts. 

The  removal  of  the  roots  of  these  teeth  is  far  more 
difficult  than  that  of  the  incisors.  Frequently  the 
gum  has  to  be  separated  up  two  or  three  lines  on  the 
alveolus,  and  the  latter  broken  in  with  the  forceps, 
before  the  root  is  removed.  The  compound  screw  is 
often  very  valuable  in  the  removal  of  these  roots — 


EXTRACTION    OF   TEETH.  323 

the  simple  screw  not  commonly  being  of  much  avail, 
since  the  force  necessary  to  extract  the  root,  is  gene- 
rally so  great  that  the  screw  alone  will  not  take  a 
sufficiently  firm  hold  to  accomplish  it.  The  elevator 
is  not  a  very  efficient  instrument  in  the  removal  of 
these  roots. 

Superior  Bicuspids. — For  the  removal  of  the  bicus- 
pid teeth  of  both  sides,  one  pair  of  forceps  is  quite 
sufficient  (see  Fig.  41).  These  forceps  are  without 
any  curve ;  though,  in  a  small  mouth,  for  the  second 
bicuspids,  a  slight  anterior  curve  would  be  desirable, 
since  it  would  admit  the  instrument  to  a  better  position 
on  the  tooth.  These  forceps  properly  adjusted  on  the 
tooth,  according  to  the  directions  already  given,  the 
attachment  is  broken  up  by  an  inward  and  outward 
movement,  carried  just  to  the  extent  necessary  to 
accomplish  the  object ;  and  then,  traction  is  applied 
to  remove  the  tooth  from  the  socket.  This  applica- 
tion of  the  force  is  specially  adapted  to  the  first 
bicuspids.  Rotary  motion  should  be  very  seldom 
applied  to  these  teeth,  because  their  points  generally 
terminate  in  a  bifurcation,  and  it  is  impracticable 
thus  to  detach  them  without  breaking  off,  at  least, 
one  of  the  fangs ;  and,  where  these  fangs  do  not  bifur- 
cate, they  are  so  much  compressed  as  generally  to 
forbid  such  a  force.  Occasionally,  however,  there  is 
but  one  fang,  and  this  is  nearly  cylindrical,  as  will 
be  indicated  by  the  cylindrical  form  of  the  crown 


324  EXTRACTION    OF   TEETH. 

and  neck  of  the  tooth ;  and,  in  such  cases,  the  rotary 
may  be  combined  with  the  inward  and  outward 
motion.  The  roots  of  the  second  bicuspids  com- 
monly terminate  in  one  conical  fang,  usually  some- 
what compressed  ;  and,  in  general,  the  rotary  motion 
may  be  combined  with  the  inward  and  outward  in 
their  extraction.  There  is  occasionally,  however, 
some  curvature  to  these  roots ;  but  very  seldom  is  it 
sufficient  to  cause  any  difficulty  in  their  removal. 
The  skillful  and  experienced  operator  will,  in  most 
cases,  determine  very  accurately  the  size,  shape,  and 
position  of  the  fangs  by  the  peculiarities  of  the 
crown  ;  and  the  attention  of  the  young  practitioner 
should  be  directed  very  closely  to  this  point,  till  he 
is  able  to  arrive  at  accurate  conclusions.  For  the 
removal  of  these  teeth,  there  are  forceps  with  thick, 
peculiarly-formed  beaks,  constructed  to  take  advan- 
tage of  the  conical  form  of  the  roots.  The  instru- 
ment is  placed  on  the  tooth  at  the  border  of  the  alve- 
olus, or,  if  need  be,  a  little  beyond  it ;  and  then,  the 
process  having  been  first  cut  awa}',  firm  compression 
is  made  on  the  handle  of  the  instrument,  and  thus 
great  pressure  on  two  sides  of  the  root, — which  are 
relatively  as  two  inclined  planes, — by  which  the 
tooth  is  forced  directly  from  its  socket,  without 
either  the  oscillating  or  the  rotary  motion.  This 
instrument  is  rarely  ever  applicable  to  the  removal 
of  any  other  teeth  than  the  second  bicuspids,  and 


EXTRACTION    OF   TEETH.  325 

occasionally  the  central  incisors,  and  then  only 
when  the  roots  are  very  tapering.  The  roots  of  the 
bicuspids,  especially  the  second,  are  usually  not  diffi- 
cult to  remove.  Sometimes,  however,  the  first  bicus- 
pids have  two  well-formed  roots,  somewhat  divergent, 
that  are  difficult  to  remove,  especially  if  the  decay 
has  eaten  away  till  there  is  little  of  the  tooth  left  for 
the  instrument  to  take  hold  upon.  But,  frequently, 
if  one  of  the  contiguous  teeth  is  absent,  a  lateral 
seizure  will  remove  the  root  at  once. 

Root  forceps  with  narrow,  thin  beaks,  which  may 
be  readily  forced  between  the  root  and  the  alveolus, 
are  very  valuable  for  the  extraction  of  all  small 
roots. 

The  screw,  whether  simple  or  compound,  is  not  ap- 
plicable to  the  extraction  of  the  roots  of  the  bicus- 
pids. 

A  bicuspid  will  sometimes  stand  somewhat  out  of 
the  true  circle,  and  the  contiguous  teeth  approximate 
so  that  it  will  not  pass  between  them.  In  such  a 
case,  the  principal  part  of  the  movement  for  its  de- 
tachment should  be  in  the  direction  of  its  inclination. 
The  cuspid  teeth  are  sometimes  found  in  the  same 
condition,  and  a  similar  application  of  force  for  their 
removal  is  to  be  made  ;  indeed,  this  method  is  appro- 
priate to  all  cases  where  the  teeth  stand  out  of  a 
proper  position  and  the  contiguous  teeth  impinge  on 
the  space. 


326  EXTRACTION    OF   TEETH. 

Superior  Molars. — The  first  and  the  second  superior 
molars  have  each  three  fangs,  one  buccal,  and  two 
palatal ;  the  palatal  being  the  largest  and  longest, 
and  the  buccal  of  the  first  larger  than  that  of  the 
second.  The  palatal  fangs  diverge  very  considerably 
from  the  axis  of  the  tooth ;  while  the  buccal  are 
often  parallel  with  it  and  with  each  other ;  but  they 
sometimes  diverge  in  both  directions.  Occasionally, 
the  divergence  of  some  or  all  of  these  fangs,  is  so 
great  that  they  can  not  pass  out  of  the  socket  with- 
out either  fracturing  the  alveolus  or  breaking  off  one 
or  more  of  the  roots.  On  the  contrary,  there  is 
sometimes  such  a  convergence  of  the  buccal  fangs, 
that  the  intervening  portion  of  bone  is  necessarily 
brought  away  with  the  tooth.  Indeed,  the  three 
fangs  are  sometimes  found  all  in  contact,  forming  an 
irregular  conical  root ;  but  this  is  a  condition  of  un- 
natural development. 

The  appropriate  forceps  being  firmly  fixed  on  the 
tooth,  an  outward  and  inward  movement  is  applied, 
and  traction  at  the  same  time.  In  the  examination 
of  these  teeth,  to  ascertain  the  force  necessary  for 
their  removal,  two  particulars  have  to  be  considered  : 
the  firmness  of  the  attachment,  and  the  position  and 
inclination  of  the  roots.  When  these  teeth,  as  they 
occasionally  do,  stand  somewhat  outside  of  the  cor- 
rect position,  great  care  must  be  exercised  in  their 
removal,  especially  if  the  contiguous  teeth  impinge. 


EXTRACTION    OF    TEETH.  327 

In  small  mouths,  the  contiguous  impinging  tooth  is 
liable  to  be  injured  by  the  pressure  in  extraction ;  but 
this  injury  may  be  avoided  by  directing  the  pressure 
backward.  Commonly,  the  first  effort  made  to  break 
up  the  attachment,  should  be  outward ;  except  where 
the  tooth  stands  inside  of  the  circle,  or  where  it  is 
decayed  very  much  on  its  inner  side,  while  its  outer 
remains  firm.  In  those  cases  in  which  the  fangs 
diverge  so  much  that  they  will  not  pass  out  of  the 
socket,  without  tearing  away  some  of  the  wall  of  the 
alveolus,  it  would  be  impossible  to  break  up  the  at- 
tachment by  an  inward  movement ;  for  the  palatal 
fangs  brace  the  tooth,  and  the  inner  process  is  very 
strong  and  unyielding.  Where  a  molar  is  decayed 
on  its  proximal  sides,  and  the  contiguous  teeth  en- 
croach on  it,  so  that  it  can  not  pass  out  directly  be- 
tween them,  it  must  either  be  cut  away  with  the 
chisel  or  file  till  it  is  small  enough  to  pass,  or  be 
drawn  to  the  outside  from  between. 

The  decay  on  the  buccal  or  palatal  sides  often 
extends  below  the  gum,  and  even  below  the  border 
of  the  alveolus ;  or  there  may  be  extensive  softening 
of  the  dentine  of  the  crown ;  and  in  either  case,  the 
gum  and  process  must  be  cut  away  sufficiently  to 
admit  a  firm  hold  on  the  tooth  where  it  is  strong 
enough  to  sustain  the  embrace  of  the  forceps. 

Extraction  of  Roots. — The  extraction  of  the  roots 
of  the  superior  molars  is   not  attended  with  much 


328  EXTRACTION    OF   TEETH. 

difficulty  when  they  are  separated  by  decay,  or  are 
easily  broken  apart ;  the  method  then  is  the  same  as 
for  single  roots.  They  should  be  deeply  embraced 
with  the  curved,  sharp-pointed  root  forceps  (see  Fig. 
46),  and  rotated  to  break  up  the  attachment,  trac- 
tion being  applied  at  the  same  time.  It  is  very 
rarely  necessary  to  resort  either  to  the  elevator  or  to 
the  screw  for  the  removal  of  these  roots.  The 
greatest  difficulty  is  experienced  when  the  bifurca- 
tion is  deep,  and  the  roots  all  adhere  firmly  together. 
In  such  case,  the  same  force  is  required  for  their 
removal  as  before  the  crown  was  decayed  off.  The 
root  forceps,  shown  in  Fig.  43,  can  be  very  effect- 
ively used  in  the  extraction  of  these  roots.  The 
round,  sharp  beak  is  passed  between  the  buccal  and 
the  palatal  fangs,  the  other  beak  embracing  the 
palatal;  and  with  this  hold,  by  an  inward  and  out- 
ward movement,  the  root  is  removed.  These  forceps 
are  not  applicable  where  there  is  but  one  large  coni- 
cal root.  For  the  removal  of  roots  of  this  form,  the 
wisdom-tooth  forceps,  or  those  with  similar  beaks, 
are  required.  When  it  is  necessary  to  dissect  off  the 
gum,  and  cut  away  the  process,  in  order  to  obtain  a 
firm  hold  of  the  root,  this  should  be  done  in  preference 
to  crushing  in  the  process  with  forceps — except,  indeed, 
it  may  be  the  case  of  a  very  irritable  patient,  who  will 
not  tolerate  a  protracted  operation ;  in  which  case,  it 
is  better  to  complete  the  operation  at  a  single  effort. 


REMOVAL  OF  THE  DENTES  SAPIENTL&.        329 
REMOVAL  OF  THE  DENTES  SAPIENTL&. 

There  is  not  usually  much  difficulty  attending  the 
extraction  of  these  teeth.  The  appropriate  forceps 
for  this  purpo.se  (see  Figs.  44  and  49)  have  two  large 
single-concave  beaks,  so  formed  as  to  embrace  the 
neck  of  the  tooth,  without  any  reference  to  the  bifur- 
cation or  the  number  and  position  of  the  fangs. 
Ordinarily,  the  attachment  of  these  teeth  is  broken 
up  by  the  inward  and  outward  movement ;  but 
where  a  single,  round,  conical  root  is  clearly  indi- 
cated, the  rotary  movement  would  be  preferable,  or 
the  rotary  in  conjunction  with  the  inward  and  out- 
ward. These  teeth  sometimes  stand  out  of  the  true 
position,  more  frequently  inclining  outward,  as 
already  suggested  in  an  other  place ;  and  the  direc- 
tion of  the  force  for  their  extraction  will  correspond 
with  this  inclination. 

Sometimes  these  teeth  are  very  difficult  to  extract ; 
and  this  difficulty  is  dependent  on  the  following  cir- 
cumstances :  first,  an  anterior  inclination  of  the 
tooth,  so  that  it  stands  at  a  considerable  angle  with 
the  adjoining  tooth,  and  in  contact  with  its  posterior 
proximal  surface,  the  posterior  border  of  the  process 
being  thick  and  firm,  and  extending  down  full  on  the 
crown  of  the  tooth ;  and  second,  the  existence  of 
several  fangs,  with  great  divergence,  irregularity, 
and  curvature.     The  removal  of  a  tooth  in  the  first 


330  EXTRACTION    OF    TEETH. 

of  these  conditions  is  often  a  very  protracted  opera- 
tion, fraught  with  much  pain  to  the  patient  and  con- 
siderable labor  to  the  operator.  Such  preparation 
must  be  made  as  will  permit  a  free  egress  of  the 
tooth  from  the  socket,  before  an  effort  is  made  for  its 
extraction.  This  is  effected  either  by  cutting  away 
the  portion  of  process  behind  the  tooth,  so  that  it 
may  be  forced  backward  sufficiently  to  let  it  pass  out 
of  the  socket,  or  by  cutting  away  enough  from  the 
anterior  portion  of  the  tooth ;  or,  if  the  posterior 
proximal  surface  of  the  second  molar  is  decayed,  it 
may  be  quite  as  well,  and  more  convenient,  to  cut 
this  down  so  as  to  allow  of  the  egress. 

Physic's  forceps  can  be  used  very  effectively  for  the 
extraction  of  these  teeth,  when  they  occupy  such  a  posi- 
tion, provided  the  root  is  straight,  or  has  a  posterior 
curvature  ;  but  if  there  is  an  anterior  curvature,  the 
tooth  is  most  difficult  to  extract,  and  Physic's  forceps 
would  be  wholly  inefficient — except  to  break  off  the 
tooth.  In  such  case,  the  posterior  portion  of  the 
process  should  be  cut  away  as  much  as  possible. 
Physic's  forceps  are  frequently  employed  for  the 
removal  of  these  teeth,  when  they  occupy  a  correct 
position  ;  but  their  use  is  somewhat  objectionable, 
especially  in  the  following  respects  :  the  instrument 
acts  first  on  the  principle  of  a  wedge,  being  forced 
between  the  teeth,  and  then  on  that  of  a  lever,  the 
second  molar  being  the  fulcrum  ;  and  hence,  when  it 


INFERIOR   INCISORS.  331 

is  employed,  the  second  molar  must  always  be  pres- 
ent, and  is  liable  to  injury  from  the  pressure  which 
may  do  violence  to  the  periosteum,  or  fracture  and 
scale  off  portions  of  the  enamel.  But  if  the  first 
molar  is  absent,  there  is  almost  as  much  liability, 
with  the  forceps,  of  loosening  the  second  as  of  ex- 
tracting the  third.  Indeed,  it  is  always  objectionable 
to  use  a  sound  tooth,  under  any  circumstances,  as  a 
fulcrum  for  an  extracting  instrument. 

When  the  roots  of  a  wisdom  tooth  are  irregular  in 
number,  inclination,  and  curvature,  a  good  firm  grasp 
must  be  taken  on  it,  and  then  an  oscillating  force 
applied,  sufficient  to  remove  it  from  its  socket. 
There  is  nothing  pertaining  to  the  removal  of  the 
roots  of  these  teeth  that  involves  any  different  prin- 
ciple or  application  of  instruments  from  that  given 
for  the  removal  of  the  teeth  themselves.  The  ante- 
rior inclination  which  so  often  renders  the  whole 
tooth  difficult  of  extraction,  very  seldom  affects  the 
removal  of  the  roots.  These  are,  in  general,  easily 
extracted  with  the  common  curved-root  forceps. 

'EXTRACTION    OF    THE    INFERIOR    INCISORS. 

In  the  extraction  of  these  teeth,  either  of  the  for- 
ceps described  for  the  purpose,  may  be  employed. 
The  beaks  should  be  quite  narrow  and  thin  (see  Fig. 
45).     The  instrument  well  fixed  on  the  tooth,  the 


332  EXTRACTION    OP    TEETH. 

attachment  is  broken  up  by  the  inward  and  outward 
movement,  the  rotary  being  seldom  applicable,  since, 
in  general,  the  roots  are  flattened,  and  in  many  cases 
quite  thin,  so  as  to  be  incapable  of  turning  in  the 
socket.  Care  must  be  exercised  in  the  oscillating 
movement,  and  especially  where  the  tooth  to  be  ex- 
tracted stands  out  of  the  proper  position,  and  the  con- 
tiguous teeth  incline  together ;  though  this  is  of  little 
consequence  where  the  teeth  are  all  to  be  removed. 
When  the  crowns  of  these  teeth  are  short  and  thick, 
the  roots  are  shorter,  thicker,  more  conical,  and  more 
nearly  cylindrical ;  and,  in  the  extraction  of  such,  the 
rotary  may  be  combined  with  the  oscillating  movement. 
Roots. — There  is  seldom  any  superadded  difficulty 
in  the  removal  of  the  roots  of  these  teeth,  the  same 
instruments  and  movements  being  applicable  as  to 
the  removal  of  the  teeth  themselves.  The  only  dif- 
ference in  any  respect  is,  that  where  the  teeth  are 
decayed  off  far  down,  the  forceps  should  be  forced 
down  on  the  process,  in  order  to  obtain  a  firm  hold 
on  the  root.  Neither  the  elevator  nor  the  screw  is 
ever  required  for  the  removal  of  these  roots. 

« 

INFERIOR    CUSPIDS. 

These  teeth  may  be  removed  with  the  inferior-bicus- 
pid forceps  of  the  right  side;  though  an  instrument 
of  the  same  general  form,  but  of  less  curvature  would 


INFERIOR    CUSPIDS.  333 

be  preferable,  since  with  such,  the  required  movement 
for  breaking  up  the  attachment  could  be  more  easily 
given.  They  commonly  have  long,  round,  conical 
roots,  not  so  large  as  those  of  the  superior  cuspids, 
nor  so  difficult  to  extract — seldom  having  any  curva- 
ture, and  thus  being  susceptible  of  detachment  by  the 
rotary  motion.  They  often  stand  so  much  anterior 
to  the  true  circle,  that  an  attempt  to  thrust  them  in- 
ward, would  be  liable  to  break  or  loosen  the  lateral 
incisors.  Their  situation,  as  indeed  that  of  all  teeth, 
should  be  strictly  attended  to  before  any  attempt  is 
made  to  remove  them. 

The  crowns  of  these  teeth  decay  off,  and  leave  the 
roots  standing,  far  more  frequently  than  do  those  of 
the  superior  cuspids.  But  there  is  no  difficulty  in  the 
removal  of  their  roots ;  and  the  only  indication  is, 
when  they  are  deeply  decayed,  to  pass  the  forceps  far 
down  on  them,  either  first  cutting  away  the  process  or 
embracing  it,  as  the  circumstances  may  warrant;  the 
former  method  being  preferable.  After  the  root  is 
extracted,  the  fractured  pieces  of  process,  if  any, 
should  be  removed. 

A  long,  tapering  screw  may  sometimes  be  advan- 
tageously used  for  the  extraction  of  these  roots,  when 
they  are  decayed  so  deeply  that  an  extensive  break- 
ing-away  of  the  process  would  be  incident  to  their  re- 
moval with  the  forceps.  The  elevator,  however,  is 
rarely  ever  called  into  requisition  here. 


334  EXTRACTION    OF   TEETH. 

INFERIOR   BICUSPIDS. 

These  teeth,  two  in  number  on  each  side,  have  but 
one  fang,  and  that  generally  round,  or  nearly  so,  and 
not  so  long  as  that  of  the  cuspids ;  and  have  less  diam- 
eter at  the  neck  than  they.  They  require,  in  ex- 
traction, forceps  for  each  side,  as  already  described 
(see  Fig.  47).  They  may  be  removed  either  by  the 
rotary,  or  by  the  inward  and  outward  movement,  or 
by  both  combined.  With  the  handle  of  the  forceps 
thrown  very  far  out  of  a  line  with  the  axis  of  the 
tooth,  this  is  always  more  difficult  to  be  rotated  ac- 
curately in  its  socket ;  a  straight  instrument  is  best 
for  the  rotary  motion.  In  the  removal  of  these  teeth 
from  the  right  side,  when  the  mouth  is  small,  care 
should  be  taken  that  too  much  pressure  is  not  made 
against  the  anterior  tooth.  This  accident  is  more 
liable  to  happen  in  the  removal  of  the  second  bicus- 
pid, than  in  that  of  the  first,  and  especially  if  the 
mouth  can  not  be  opened  wide.  As  the  tooth  comes 
out,  the  forceps  are  liable,  without  some  attention,  to 
strike  the  superior  teeth,  and  in  this  way  fracture 
them  or  scale  off  their  enamel.  In  many  cases,  for- 
ceps with  a  forward  and  an  outward  curvature  com- 
bined, would  be  very  desirable,  for  facility  of  ap- 
proaching the  tooth ;  but  with  such  a  complication 
of  curves,  the  operator  loses  control  of  the  instru- 
ment. 


INFERIOR   MOLARS.  335 

In  the  removal  of  the  bicuspids  of  the  left  side, 
there  is  little  or  no  liability  to  undue  pressure  against 
the  anterior  teeth ;  and  in  their  extraction,  the  move- 
ment should  be  mainly  inward  and  outward,  since 
the  great  curvature  of  the  forceps  renders  a  rotary 
motion  very  difficult  and  uncertain.  There  is  also 
danger  here  of  striking  the  upper  teeth,  especially  if 
the  tooth  to  be  extracted  comes  out  with  less  effort 
than  the  operator  anticipated ;  an  accident  that 
sometimes  befals  the  most  skillful  and  discriminative. 
The  first  and  the  second  inferior  bicuspids  are  re- 
moved with  about  equal  facility. 

Occasionally,  though  seldom,  these  teeth  have  two 
distinct,  well-defined  roots ;  a  condition  that  can  not 
be  determined  by  the  form  of  the  crown  or  by  any 
other  visible  indication  ;  and  one  tooth  alone  will 
sometimes  be  found  with  this  peculiarity.  The  re- 
moval of  the  roots  of  these  teeth  is  not  attended  with 
much  difficulty  ;  the  main  consideration  being,  to  ob- 
tain a  deep,  strong  hold  on  them,  and  then  apply  a 
firm,  steady  movement. 

INFERIOR    MOLARS. 

These  teeth  commonly  have  two  fangs,  a  posterior 
and  an  anterior ;  the  latter  being  the  largest,  and  fre- 
quently the  longest.  The  roots  have  different  incli- 
nations to  the  axis  of  the  tooth,  being  in  some  cases 


336  EXTRACTION    OF   TEETH. 

divergent  from,  and  in  others  parallel  with  it,  and  in 
others  convergent,  or  curved  together  so  that  their 
points  almost  meet.  The  forms  of  the  crowns  will 
give  some  indication  of  the  inclinations  of  the  fangs  : 
if  those  are  short,  these  are  so,  and  vice  versa  ;  if  the 
diameter  of  the  crown  is  about  the  same  at  the  mas- 
ticatory surface  and  the  neck,  the  fangs  do  not 
diverge ;  if  the  crown  is  long  and  of  uniform  diam- 
eter, the  fangs  will  be  either  parallel  or  convergent; 
and  if  the  angles  on  the  crown  are  not  sharp  and  well 
defined,  the  roots  most  probably  curve  together  at 
the  points.  If,  however,  the  angles  formed  by  the 
masticatory  and  lateral  surfaces  of  the  teeth  are 
sharp  and  well  defined,  the  roots  generally  diverge. 

Forceps  adapted  to  each  side  are  required  for  the 
removal  of  these  teeth.  These  forceps  have  a  promi- 
nence, or  point,  in  the  center  of  the  beaks,  to  pass 
into  the  bifurcation;  and,  in  separating  the  gum,  it  is 
important  to  dissect  it  away,  and,  if  need  be,  even 
cut  away  the  margin  of  the  process,  so  that  the  bifur- 
cation may  be  well  exposed,  to  admit  the  forceps  to 
a  proper  position  on  the  tooth,  without  obstruction. 
The  tooth  being  firmly  grasped  in  the  proper  manner 
by  the  forceps,  is  moved  gradually,  but  steadily, 
inward  and  outward,  to  break  up  the  attachment, 
and  then  drawn  from  its  socket.  In  the  removal  of 
these  teeth  from  the  right  side  with  the  ordinary  for- 
ceps, there  is  great  danger  of  undue  pressure  on  the 


INFERIOR    MOLARS.  337 

anterior  contiguous  teeth ;  which  is  to  be  avoided  by 
directing  the  pressure  backward  in  the  operation. 
And  there  is  also  danger  of  injuring  the  upper  teeth 
with  the  forceps;  which  maybe  obviated  by  wrap- 
ping the  joint  of  the  instrument  with  a  small  napkin. 

In  the  removal  of  the  inferior  molars  of  the  left 
side,  the  application  of  force  is  the  same — an  inward 
and  outward  movement — but  the  handles  of  the  for- 
ceps occupy  different  relative  positions  to  the  teeth 
to  be  extracted,  passing  directly  out  at  the  front  of 
the  mouth,  in  stead  of  at  one  side.  In  consequence 
of  this  arrangement,  the  operator  can  not  exert  the 
same  force  on  them,  as,  with  the  proper  forceps,  on 
those  of  the  right  side.  Very  little  traction  can  be 
employed  in  connection  with  the  oscillating  move- 
ment, but  the  attachment  must  be  almost  wholly 
broken  up  before  beginning  to  lift  the  tooth  from  the 
socket.  But  in  extracting  the  teeth  on  the  right 
side,  with  the  proper  forceps,  traction  is  always  com- 
bined with  the  to-and-fro  movement. 

In  the  extraction  of  the  roots  of  these  teeth,  little 
difficulty  is  experienced  after  the  decay  has  pro- 
ceeded so  far  as  to  effect  their  separation.  They  nre 
then  embraced  with  the  appropriate  forceps,  and 
removed  as  single  roots  are  elsewhere.  These  for- 
ceps have  narrow,  thin,  sharp  beaks,  turned  to  almost 
a  right  angle.  With  them,  the  root  is  embraced,  and 
moved  inward  and  outward  till  loosened,  and  then 


338 


EXTRACTION    OF    TEETH. 


removed.  When  the  mouth  is  large,  and  can  be 
opened  wide,  the  slightly  curved  root  forceps  are 
convenient,  and  the  rotary  movement  may  be  em- 
ployed with  them,  if  the  roots  are  not  very  much 
curved,  flattened,  or  firmly  set.  The  removal  of 
these  roots  is  more  difficult  when  the  bifurcation  is 
low  down,  and  the  roots  remain  firmly  attached  to- 
gether, and  especially  when  they  diverge.  If  the  bi- 
furcation is  not  too  low,  and  the  attachment  not  too 
firm,  the  roots  may  be  separated  with  the  separating 
forceps  (Fig.  63),  and  then  removed  singly,  as  in 
other  cases.     This  is  the   preferable  method,  when 

Fie.  63. 


there  is  much  divergence ;  but  if  the  fangs  can  not 
be  separated,  they  may  be  extracted  with  the  forceps 
shown  in  Fig.  52.  The  round,  curved,  sharp  beaks 
are  passed  down  between  the  roots,  and  the  whole  is 
removed  at  once ;  the  attachment  being  broken  up  on 
the  principle  already  described. 

These  teeth  sometimes  have  but  one,  large,  round, 
conical  fang;  and  there  is  seldom,  if  ever,  enough 
curvature  of  the  roots  to  render  extraction  difficult. 


INFERIOR    DENTES    SAPIENTLE.  339 

The  ordinary  inferior-molar  forceps  are  not  well 
adapted  to  the  purpose;  for  the  central  points  of 
their  beaks  will  prevent  a  perfect  adaptation.  The 
broad,  single-concave,  beaked  forceps  are  best  adapted ; 
the  curves  and  general  forms  of  which,  except  the 
beaks,  are  the  same  as  those  represented  in  Fig.  49. 
The  removal  of  teeth  with  this  kind  of  roots  is  easily 
accomplished.  Rotary  movement  would  be  appli- 
cable here,  if  the  exact  form  of  the  root  could  be 
ascertained  before  extraction ;  but  it  is,  in  general, 
the  safest  course  to  employ  the  inward  and  outward 
movement. 


INFERIOR   DENTES    SAPIENTLE. 

These  teeth  require,  for  their  removal,  the  broad, 
single-concave,  beaked  forceps,  the  beaks  curved  at  a 
right  angle  with  the  handle,  and  the  handle  straight. 
This  instrument  fixed  deeply  and  firmly  on  the 
tooth,  the  attachment  is  to  be  broken  up  by  the 
inward  and  outward  movement.  These,  more  fre- 
quently than  the  superior  denies  sapientice,  stand  out 
of  the  proper  position ;  their  variations  and  the  man- 
ner of  obviating  the  attendant  difficulties,  however, 
being  about  the  same — at  least,  so  far  as  deviation  is 
concerned.  Physic's  forceps  may  be  used  here  with 
greater  facility  than  on  the  upper  teeth. 

These  teeth  frequently  exhibit  but  a  very  small 


340  EXTRACTION    OF   TEETH. 

portion  of  the  crown  through  the  gum.  Being 
erupted  with  an  anterior  inclination,  the  tooth  comes 
in  contact  with  the  posterior  portion  of  the  second 
molar,  and  is  thus  checked  in  its  external  develop- 
ment. Thus  the  crown  is  left  partially  covered  with 
the  gum,  which  frequently  inflames,  and  even  sup- 
purates, remaining  in  that  condition  for  a  consider- 
able time,  to  the  great  annoyance  of  the  patient. 
Such  teeth  are  difficult  to  remove ;  first,  because  of 
their  inclination  and  contact  with  the  second  molar; 
and  secondly,  because  the  crown  is  more  than  half 
below  the  borders  of  the  thick,  firm  alveolus,  render- 
ing it  impossible  to  obtain  a  firm  hold  of  the  tooth, 
without  cutting  away  a  portion  of  the  alveolus.  In 
such  cases,  it  is  generally  best  to  make  a  free  excision 
of  the  alveolus  all  round  the  tooth,  sufficient  to  per- 
mit its  easy  removal. 


EXTRACTION    PREPARATORY   TO    THE   INSERTION   OF 
ARTIFICIAL   DENTURES. 

Whenever  there  is  a  number  of  teeth  to  be  re- 
moved, the  method  and  the  duration  of  the  operation 
will  depend  on  the  following  circumstances :  first,  the 
number  to  be  removed ;  second,  the  firmness  of  their 
attachment;  third,  the  patient's  power  of  endurance; 
and  fourth,  the  manner  in  which  the  immediate  parts 
are  affected.     Where  the  number  to  be  removed  is 


EXTRACTION    PREPARATORY   TO   INSERTION.  341 

considerable,  and  the  attachment  is  feeble,  or  not 
very  firm,  and  the  patient's  power  of  endurance  good, 
the  extraction  may  be  as  rapid  as  is  consistent  with 
efficiency.  In  many  such  cases,  from  three  to  six 
teeth  may  be  removed,  without  any  relaxation,  by 
the  operator,  of  his  hold  on  the  parts  with  the  left 
hand.  This  is  generally  practicable  with  the  front 
teeth  of  the  lower,  and  frequently  with  those  of  the 
upper  jaw ;  but  it  is  not  proper  to  remove  more  than 
three  or  four  of  the  molar  teeth,  without  respite,  even 
when  they  are  quite  loose,  or  have  but  a  feeble 
attachment  in  the  socket.  The  gum  should,  of 
course,  be  well  separated  previously  to  the  operation. 
Only  so  many  teeth  should  be  removed  at  one  sitting 
as  the  nervous  system  will  allow  without  too  great  a 
shock.  In  many  instances,  however,  it  is  practi- 
cable, so  far  as  this  is  concerned,  to  remove  at  once 
all  the  teeth  in  the  mouth.  In  the  extraction  of  a 
large  number,  those  most  easily  removed  should  be 
first  taken,  so  as  by  degrees  to  bring  the  patient  to 
severer  operations.  If  there  is  a  manifest  hemor- 
rhagic diathesis — a  disposition  to  bleed  freely  from 
the  capillaries,  as  well  as  from  the  larger  vessels — 
but  two  or  three  teeth  should  be  removed  at  a  sit- 
ting, lest  uncontrollable  hemorrhage  ensue. 

After  all  the  teeth  are  removed  from  one  or  both 
of  the  jaws,  the  gums  and  alveolus  should  undergo  a 
trimming  process :  all  detached,  flabby,  or  prominent 


342  EXTRACTION    OF    TEETH. 

portions  of  the  gums  should  be  dissected  off;  the 
whole  ridge  made  uniform ;  all  loose  portions  of  the 
alveolus  removed;  all  the  prominent  points  and  sharp 
edges  cut  down  ;  and  the  whole  border  of  the  process 
rendered  as  smooth  and  even  as  possible.  By  this 
means,  the  healing  of  the  parts  is  facilitated,  and  they 
assume  the  desired  condition  and  form  in  much  less 
time,  and  with  far  less  soreness  and  inconvenience. 

CONDITIONS    TO    BE    OBSERVED    IN    THE    EXTRACTION. 

Such  conditions  are  often  found  to  exist  in  the 
system,  as  indicate  the  necessity  of  great  care  in  the 
operation,  or  of  prior  treatment,  or  forbid  the  extrac- 
tion of  the  teeth  altogether.  Of  these  conditions,  the 
following  are  some  of  the  more  obvious  : 

Extreme  debility. 

Great  nervous  irritability. 

Excessive  local  inflammation,  especially  where  it 
tends  to  the  other  parts. 

Much  irritability  of  the  parts  intimately  connected 
with  the  teeth. 

Pregnancy,  and  all  uterine  irritations. 

A  tendency  to  epilepsy. 

In  many  cases,  where  there  is  great  debility,  so 
painful  an  operation  as  the  extraction  of  a  tooth,  will 
cause  extreme,  and  sometimes  alarming  prostration. 
This,  however,  may  be  anticipated,  by  prior  invigo- 


CONDITIONS    TO    BE    OBSERVED    IN    EXTRACTION.         343 

rating  treatment,  continued  till  strength  and  tone  are 
obtained  sufficient  to  endure  the  operation.  This 
treatment  may  occupy  considerable  time ;  while  an 
urgent  case  may  arise,  in  which  the  removal  of  the 
offending  tooth  is  immediately  demanded ;  in  which 
case,  it  is  proper  to  administer  stimulants — brandy  or 
wine,  or  such  as  the  case  may  seem  to  require.  By 
such  means,  the  system  may  be  so  invigorated  as  to 
withstand  the  shock  of  the  operation  with  compara- 
tive fortitude. 

There  is  in  some  cases  a  highly  irritable  condition 
of  the  nervous  system,  that  almost  absolutely  forbids 
the  extraction  of  teeth,  convulsions  being  sometimes 
produced,  in  such  cases,  by  a  simple  operation.  This 
remark  does  not  of  course  apply  to  facial  neuralgia 
that  may  be  either  partially  or  wholly  produced  and 
kept  up  by  diseased  teeth  ;  neither  general  nor  local 
neuralgia  would  be  aggravated  by  an  operation  of 
this  kind.  Accompanying  general  nervous  irrita- 
bility, there  is  usually  excessive  dread  of  an  opera- 
tion, such  as  to  occasion  rapid  prostration  —  even 
greater  and  more  rapid  than  that  caused  by  the  ope- 
ration itself.  In  such  cases,  if  the  extraction  is 
effected  immediately,  it  will  give  relief;  but  where 
the  excitement  has  been  very  high,  and  the  tension 
for  some  time  great,  the  depression  after  the  opera- 
tion will  be  correspondingly  great,  and  considerable 
time  be  required  for  complete  recovery ;  indeed,  the 


344  EXTRACTION    OF    TEETH. 

shock  is  sometimes  so  severe  as  to  occasion  confine- 
ment for  several  days.  Treatment  for  quieting  the 
nervous  system,  consisting  in  agents  of  a  sedative, 
nervine  character,  may  be  employed  previously  to 
the  operation  :  stimulants,  as  a  general  rule,  should 
be  avoided. 

Where  there  is  a  high  state  of  inflammation  in  the 
immediate  parts,  especially  if  there  is  a  general  in- 
flammatory diathesis,  the  propriety  of  extracting  the 
teeth  is  questionable.  Under  such  circumstances, 
there  is  probably  less  danger  in  the  extraction  of  the 
inferior  teeth,  than  of  the  superior.  Where  the  in- 
flammation has  a  disposition  to  extend,  it  is  liable  to 
go  to  the  head  from  the  superior  maxilla,  and  to  the 
fauces  and  throat  from  the  inferior.  In  cases,  then, 
where  there  is  excessive  inflammation  in  the  imme- 
diate parts,  accompanied  by  a  general  inflammatory 
condition,  both  local  and  general  antiphlogistic  treat- 
ment should  be  adopted. 

Extreme  irritability,  or  a  diseased  condition  of 
parts  having  an  intimate  connection  with  the  teeth, 
as  the  immediate  surrounding  tissues,  the  salivary 
glands,  and  the  throat,  is  a  circumstance  admonish- 
ing to  great  caution  in  the  extraction  of  teeth,  espe- 
cially when  such  condition  does  not  depend  on  the 
teeth  for  its  exciting  cause  or  modifying  influence. 
It  is,  however,  very  generally  the  case,  when  any  of 
the  parts  having  an  intimate  relation  with  the  teeth, 


CONDITIONS  TO  BE  OBSERVED  IN  EXTRACTION.    345 

become  in  any  way  affected,  diseased  teeth  will  exer- 
cise an  injurious  influence  on  them.  If  the  necessity 
for  the  removal  of  the  offending  tooth  is  not  too  urgent, 
the  parts  that  may  be  diseased  about  it,  should  be 
brought  to  as  good  a  condition  as  possible. 

Pregnancy  and  uterine  irritation  frequently  pro- 
duce strong  sympathetic  influences  on  the  teeth,  and 
especially  on  those  which  are  in  an  irritable  condi- 
tion :  even  sound  teeth  may  be  thus  affected,  so  as  to 
occasion  great  annoyance.  Such  teeth  are  frequently 
presented  for  extraction ;  but  these  cases  should 
always  be  thoroughly  examined  before  deciding  as  to 
the  propriety  of  an  operation.  As  a  consequence  of 
this  sympathetic  connection  between  the  teeth  and 
the  uterus,  the  latter,  when  in  an  irritable  condition, 
is  very  liable  to  be  affected  by  any  special  violence  to 
the  former.  In  many  cases,  under  such  circum- 
stances, the  extraction  of  a  tooth  is  attended  with 
pain  in  the  uterus ;  and  in  cases  of  pregnancy,  where 
there  is  debility  of  the  parts  involved,  abortion  is 
liable  to  follow  the  operation.  It  is  the  duty  of  the 
patient,  under  such  circumstances,  to  notify  the  ope- 
rator of  the  condition;  or,  if  the  latter  has  any  know- 
ledge of  it,  it  is  his  duty  to  become  fully  acquainted 
with  the  circumstances,  and  then  to  conform  to  the 
indications.  In  such  case,  treatment  will  avail  but 
little  to  prepare  the  system  for  the  operation.  The 
better    method    is    to   adopt    palliative    treatment; 


346  EXTRACTION   OF   TEETH. 

which,  if  the  affection  is  wholly  sympathetic,  must 
be  directed  to  the  organ  producing  the  difficulty. 
But  if  the  affection  is  in  part  local,  then  topical  treat- 
ment is  also  indicated.  When  there  is  a  suppression 
of  menstruation,  there  will  be  an  increased  disposi- 
tion to  hemorrhage ;  and  in  the  extraction  of  the 
teeth  of  a  patient  of  hemorrhagic  diathesis,  this  is  a 
point  to  which  observation  should  be  very  specially 
directed  :  here,  of  course,  a  remedy  for  the  obstruc- 
tion would  meet  the  difficulty. 

Persons  subject  to  epilepsy  should  be  very  cau- 
tiously treated  in  all  operations  on  the  teeth,  and 
most  especially  in  their  extraction.  It  is  not  pro- 
bable, however,  that  an  operation  of  this  character 
would  increase  the  tendency  to  epilepsy;  but  any 
undue  excitement  is  liable  to  produce  a  paroxysm  of 
the  disease ;  and  hence  the  operator  should  proceed 
to  his  work  with  as  little  parade  as  possible ;  yet,  not 
stealthily;  the  patient  should  be  thoroughly  aware  of 
what  is  to  be  done;  for,  of  all  patients,  such  a  one  is 
the  last  that  should  be  deceived.  Of  course,  in  a  case 
of  this  kind,  there  can  be  no  prior  treatment  that  will 
avail  anything;  the  most  that  can  be  done,  is,  to 
await  the  fittest  opportunity  in  respect  to  the 
paroxysms.  There  is  no  more  liability  to  fatal  re- 
sults with  such  patients  than  with  others. 


CHAPTER  XII. 

ACCIDENTS  IN  THE  EXTRACTION  OF  TEETH. 

The  accidents  liable  to  occur  to  the  teeth  and  the 
contiguous  parts  in  the  operation  of  extraction,  used 
to  be  far  more  frequent  than  they  are  at  present. 
This  difference  results  from  the  existence  of  more 
perfect  instruments  and  of  more  accurate  and  exten- 
sive knowledge.  Formerly,  no  one  studied  the  pecu- 
liarities of  the  teeth,  either  in  their  physical  or  ana- 
tomical structure ;  their  peculiar  forms,  as  indicated 
by  their  crowns ;  their  anatomical  and  physiological 
relations  to  the  contiguous  parts  and  to  one  another; 
and  their  attachment  as  affected  by  the  character  and 
structure  of  the  tissues  about  them.  The  instruments 
employed,  too,  were,  till  within  a  few  years  past,  very 
crude  in  their  forms,  very  inapplicable  in  that  part 
which  embraces  the  tooth,  inappropriate  in  their 
shapes,  and  defective  in  their  manner  of  applying  the 
force  in  the  operation.  But  these  causes  of  accidents, 
so  far  as  the  better  part  of  the  dental  profession  is 
concerned,  have  been  in  a  very  marked  degree  dimin- 
ished. 


348  ACCIDENTS   IN   THE    EXTRACTION    OF    TEETH. 

Some  of  the  accidents  attendant  or  consequent  on 
the  extraction  of  teeth,  are  of  a  grave  character. 
Permanent  deformity  has  sometimes  been  occasioned 
by  extensive  laceration  of  the  soft  parts,  or  by  frac- 
ture of  the  alveolus  and  of  the  maxilla.  Intense 
and  protracted  suffering  frequently,  and  death  some- 
times, follows  such  accidents. 

HEMORRHAGE. 

Excessive  and  obstinate  hemorrhage  in  some  cases 
follows  the  extraction  of  teeth,  occasionally  resulting 
seriously,  and  even  fatally.  There  is  in  some  consti- 
tutions a  hemorrhagic  diathesis,  such  as  that  from  a 
small  wound,  or  even  a  scratch,  there  will  ensue  per- 
sistent bleeding.  This  condition  is  dependent,  first, 
on  a  lack  of  tone  in  the  bloodvessels,  so  that  they 
fail  to  contract  at  an  injured  or  ruptured  point ;  and 
secondly,  on  a  peculiar  condition  of  the  blood,  such 
as  to  form  coagulum  with  difficulty,  as,  when  there 
is  a  relative  deficiency  of  red  corpuscles.  It.  is  one  of 
the  most  important  duties  that  ever  devolve  on  the 
dentist,  to  make  a  correct  diagnosis  in  cases  where 
there  is  a  tendency  to  hemorrhage.  Close  attention 
to  the  following  points,  will  assist  much  in  arriving 
at  a  just  conclusion.  In  persons  of  a  hemorrhagic 
tendency,  there  is  a  lymphatic,  serous  temperament ; 
a  lack  of  tone  in  the  soft  parts — a  soft,  flabby  condi- 


HEMOKRIIAGE.  349 

tion  ;  the  skin  pale,  and  devoid  of  the  bright,  vital 
appearance  ;  the  eyes  and  hair  of  light  color ;  and  the 
flow  of  saliva  and  mucus  abundant.  Besides  these 
indications,  much  may  be  learned  sometimes  by  pro- 
perly directed  inquiries  of  the  patient  in  regard  to  a 
disposition  to  hemorrhage  on  being  wounded,  either 
in  his  own  case,  or  in  that  of  his  relatives ;  if  in  the 
former,  under  what  circumstances  ;  whether  from  an 
extensive  or  a  slight  wound ;  from  large  or  small 
vessels — from  arteries  or  veins ;  or,  whether  it  oc- 
curred immediately,  or  after  the  lapse  of  some  time. 
If  the  patient  has  never  met  with  an  accident  suffi- 
cient to  occasion  excessive  hemorrhage,  and  any  of 
his  relatives  have,  and  a  tendency  to  bleeding  is  sus- 
pected in  the  case,  the  operator  should  ascertain 
whether  there  is  a  similarity  of  temperament  and 
constitutional  tendencies  between  the  patient  and 
such  relative. 

There  are  certain  circumstances  in  which  excessive 
hemorrhage  wrould  be  more  likely  to  occur  than  in 
others ;  as,  for  instance,  when  there  is  an  accidental 
relaxation,  or  lack  of  tone,  in  the  system,  especially 
the  vascular  system  ;  and  also,  when  there  is  a  sup- 
pression of  any  periodical  discharges.  There  may  be 
excessive  hemorrhage  from  a  ruptured  vessel  when 
there  is  no  constitutional  hemorrhagic  tendency. 
There  is  sometimes  a  local  difficulty  with  the  vessels 
— a  lack  of  tone  in  the  part — on  account  of  which 


350  ACCIDENTS    IN   THE    EXTRACTION    OF   TEETH. 

obstinate  hemorrhage  will  occur.     A   peculiarity  of 
this  kind  is  not  very  readily  recognized. 

Violent  passion,  and,  indeed,  any  strong  agitation 
of  the  mind,  will  aggravate  hemorrhage.  Improper 
medication,  as  well  as  highly  stimulating  food,  will 
have  the  same  tendency.  Anything  that  will  in- 
crease the  circulation,  or  reduce  the  tone  of  the  ves- 
sels, or  change  the  condition  of  the  blood,  will 
increase  the  liability  to  hemorrhage.  Simple  deter- 
mination of  blood  to  a  part,  however,  would  not  indi- 
cate such  a  liability.  When  there  is  a  special 
hemorrhagic  diathesis,  the  blood  will  flow  from  all 
the  wounded  surface,  will  be  thrown  out  from  all  the 
ruptured  capillaries.  The  most  difficult  cases  are 
those  in  which  there  is  a  defect  both  in  the  vessels 
and  in  the  blood.  Usually,  in  such  cases,  there  is  a 
lack  of  red  corpuscles  in  the  blood,  from  which  cause 
it  does  not  normally  coagulate.  If  the  blood  is  in  a 
good  condition,  it  will  coagulate  in  ruptured  capil- 
laries, though  they  might  be  deficient  in  tone ;  but  in 
larger  vessels,  though  coagula  might  be  formed,  it 
would  not  be  retained. 

TREATMENT. 

In  cases  where  there  is  manifest  hemorrhagic  dia- 
thesis, prior  treatment  is  indicated,  if  the  necessity  of 
extraction  is  not  urgent ;  and  that  treatment  will  be 


HEMORRHAGE — TREATMENT.  351 

determined  by  the  peculiar  condition  of  the  case.  If 
there  is  a  lack  of  tone  in  the  vessels — an  inability  to 
contract — then  the  treatment  should  be  of  a  tonic 
character ;  and,  if  the  blood  is  in  good  condition,  this 
is  the  only  treatment  necessary ;  but,  if  in  a  vitiated 
state,  other  treatment  will  be  demanded ;  the  object 
of  which  is  to  produce  an  increase  of  red  corpuscles. 
It  is  always  better  to  postpone  the  operation,  if  at  all 
practicable,  till  such  treatment  can  be  had  as  will 
bring  the  system  to  the  best  possible  condition. 

Of  the  several  methods  of  arresting  hemorrhage, 
the  proper  one  in  a  given  case  will  be  determined  by 
the  circumstances.  Styptics,  or  astringents,  applied 
directly  to  the  ruptured  surface,  will  often  be  found 
to  produce  coagulation  of  the  blood,  and  thus  stop  its 
flow,  without  anything  else.  This  kind  of  remedy 
will  be  efficient  in  those  cases  in  which  the  applica- 
tion will  produce  contraction  of  the  bleeding  vessels, 
as  well  as  coagulation  of  the  blood.  Sometimes  this 
class  of  agents  will  fail  to  accomplish  the  object;  in 
which  case,  in  addition  to  them,  compression  should 
be  made  upon  the  part.  Indeed,  in  many  cases,  the 
compress  will  effect  all  that  is  desired,  without  any 
other  application. 

There  are  several  methods  of  applying  the  com- 
press ;  but  the  one  best  adapted  to  any  given  case, 
will  be  determined  by  circumstances;  such  as  the 
extent  of  the   wound,  the  character  of  the   hemor- 


352  ACCIDENTS    IN   THE    EXTRACTION    OF   TEETH. 

rhage,  the  location  of  the  injury,  and  the  size  of  the 
mouth. 

A  very  common  method  of  making  compression  in 
the  socket  from  which  a  tooth  has  been  drawn,  is,  to 
force  into  the  cavity  pledgets  of  cotton,  or  small 
strips  of  linen,  tightly,  till  it  is  full.  It  is  well  to 
saturate  these  with  a  solution  of  tannin,  or  some 
astringent  preparation,  applying  it,  too,  in  connection 
with  the  compression.  In  some  cases,  a  simple  pack- 
ing of  the  cavity  in  this  manner,  is  quite  sufficient ; 
but,  in  others,  it  is  necessary  to  retain  the  pledgets 
in  the  socket  by  means  'of  further  compression.  This 
is  effected  by  placing  a  roll  of  linen,  or  perhaps  bet- 
ter, a  properly  formed  piece  of  cork  on  the  packing, 
and  then  closing  the  jaws  tightly  upon  this,  and,  if 
need  be,  placing  a  bandage  under  the  chin,  and  tying 
it  firmly  over  the  head.  The  length  of  time  during 
which  it  will  be  necessary  to  keep  the  jaws  thus 
together,  will  depend  on  the  nature  of  the  case — 
from  one  to  six  hours.  After  the  hemorrhage  has 
entirely  ceased,  the  bandage  is  to  be  removed  care- 
fully, and  the  patient  instructed  to  hold  the  jaws 
together  on  the  compress  for  a  time,  and  then  gradu- 
ally to  open  the  mouth,  and  remove  the  cork  with 
much  caution.  After  this,  the  packing  should  re- 
main in  the  socket  from  one  to  three  days,  and  then 
be  removed  very  carefully,  one  piece  at  a  time,  lest 
the  ruptured  vessels  be  opened  up  and  the  hemor- 
rhage caused  to  recur. 


HEMORRHAGE.  353 

The  object  in  applying  a  compress  is  to  bring  it  to 
bear  upon  the  aperture  of  the  wounded  vessel,  and  in 
this  way  to  prevent  the  escape  of  blood,  till  coagulum 
is  formed  and  the  opening  permanently  closed.  The 
operator  should  ascertain  the  precise  point  from 
which  the  blood  flows,  and  form  the  compress  so  as 
to  bear  full  upon  it.  If  the  flow  is  from  all  the 
wounded  surface,  then  the  compress  must  be  made  to 
conform  exactly  to  that  throughout. 

An  other  method  of  making  the  compression,  is  to 
force  softened  wax  into  the  socket,  so  as  to  fit  it  per- 
fectly; remove  it  and  chill  it  in  cold  water;  and  then 
introduce  and  make  compression  upon  it  in  the  man- 
ner already  described,  following,  throughout,  the 
general  directions.  An  other,  and  probably  better 
method,  is,  to  form  cones  of  wax  cloth,  as  near  the 
shape  and  size  of  the  root  removed  from  the  socket 
as  possible.  This  material  is  prepared  by  dipping 
thin  linen  into  melted  beeswax,  withdrawing  it  and 
letting  it  cool,  and  then  cutting  off  strips  of  from  a 
fourth  to  a  half  an  inch  wide,  and  rolling  them  into 
the  proper  size  and  shape.  Having  softened  this 
material  by  heat,  and  freed  the  socket  of  coagulum, 
introduce  and  press  it  firmly  into  place,  making  the 
compression  on  it  as  already  directed.  This  makes 
a  very  efficient  compress  for  many  cases. 

Plaster  of  Paris  is  sometimes  used  on  the  principle 
of  a  compress.     Having   the   plaster  mixed   of  the 


354  ACCIDENTS    IN    THE   EXTRACTION    OF   TEETH. 

proper  consistence,  and  the  cavity  clear,  fill  com- 
pletely with  it,  let  it  set,  and  then  make  compression 
on  it  in  the  usual  manner. 

The  fang  of  the  tooth  is  sometimes  returned  to  the 
socket  to  serve  as  a  compress.  It  possesses  the 
advantage  of  having  a  perfect  adaptation ;  but  there 
is  a  liability  of  reunion  between  it  and  the  socket; 
though  this  can  be  obviated  by  removing  all  the 
periosteum  from  the  root.  This  method  of  compres- 
sion may  be  made  more  thorough  by  immersing  the 
root  in  melted  wax,  and  then,  before  this  becomes 
too  hard,  introducing  it  into  its  original  position. 
This  makes  a  very  perfect  and  efficient  compress.  If 
the  crown  is  still  remaining,  when  the  jaws  are 
closed  it  will  come  in  contact  with  the  opposing 
teeth,  and  thus  be  kept  firmly  in  place,  without  any- 
thing further.  It  may  be  removed  carefully  after 
from  one  to  three  days.  In  cases  where  there  is 
hemorrhage  from  the  entire  wounded  surface,  there 
will  be  a  considerable  flow  of  blood  from  the  margin 
of  the  gum,  even  after  plugging  up  the  socket,  and 
making  compression  by  either  of  the  methods  des- 
cribed. In  such  case,  after  the  socket  is  plugged  up 
as  already  described,  a  plate  is  so  fashioned  as  to  fit 
tightly  over  the  gum,  and  draw  its  margin  down 
closely  upon  the  compress.  This  pressure  on  the 
bleeding  edges  of  the  gum,  checks  the  flow  of  blood 
there.     The  plate  must  be  held  down  by  the  means 


HEMORRHAGE.  355 

already  described.  It  is  sometimes  difficult  to  obtain 
an  accurate  fit  for  the  plate,  so  as  entirely  to  prevent 
the  blood  from  continuing  to  ooze  out.  In  such 
cases,  make  the  plate  to  conform  as  nearly  as  conve- 
nient to  the  part ;  then  fill  up  its  concavity  with 
plaster  of  Paris,  mixed  to  a  proper  consistence  ;  and 
then  place  the  whole  upon  the  part,  till  the  plaster 
conforms  exactly  to  it,  and  retain  it  there  till  the 
plaster  sets.  This  is  then  used  for  the  compress. 
Or  the  inside  of  the  plate  may  be  thickly  coated  with 
softened  gutta  percha,  in  stead  of  plaster,  and  pressed 
upon  the  part  in  the  manner  already  described,  and 
employed  in  the  same  way. 

It  will  often  require  considerable  discrimination  to 
determine  the  best  method  of  obtaining  compression. 
Very  great  difficulty  is  occasionally  experienced  when 
a  portion  of  the  process  has  been  broken  away,  or  the 
soft  parts  have  been  lacerated. 

Various  preparations  are  used  as  hemostatics. 
These  agents  serve  to  check  hemorrhage  in  two 
ways:  first,  by  facilitating  a  coagulation  of  the  blood; 
and  secondly,  by  producing  a  contraction  of  the  ori- 
fice of  the  ruptured  vessels.  It  is  proper  in  all  cases 
to  use  styptics  in  connection  with  the  compress.  The 
following  agents  have  been  used  as  styptics  :  tannic 
acid,  creosote,  nitrate  of  silver,  chlorid  of  zinc,  sul- 
phate of  zinc,  oil  of  turpentine,  muriate  of  iron.  The 
methods  of  applying  these  different  preparations  are 


356  ACCIDENTS    IN    THE    EXTRACTION    OP   TEETH. 

the  same.  The  agent  is  simply  to  be  retained  in 
contact  with  the  part  till  it  has  exerted  its  influence. 
A  solution  of  tannin  in  alcohol  with  creosote,  equal 
parts,  makes  a  very  powerful  styptic. 

The  actual  cautery  is  sometimes  used  to  arrest 
hemorrhage  ;  but  the  propriety  of  using  it  in  cases 
where  there  is  a  manifest  hemorrhagic  diathesis,  is 
exceedingly  doubtful.  When  the  scar  produced  by 
the  hot  iron  is  sloughed  off,  the  hemorrhage  is  liable 
to  occur  with  increased  vigor,  indeed,  is  certain  to  do 
so  in  almost  every  case  when  there  is  a  strong  pre- 
disposition. Constitutional  treatment  may  be  em- 
ployed to  anticipate  hemorrhage  ;  and  it  should  have 
in  view  an  increase  of  the  relative  amount  of  red  cor- 
puscles in  the  blood,  and  a  diminution  of  the  serous 
portion,  and  also  the  production  of  a  normal  tone  of 
the  system.  Saline  purgatives  may  be  used  with 
very  decided  advantage,  followed  with  acetate  of  lead, 
in  connection  with  opium;  the  effect  of  the  lead  being 
to  increase  the  coagulability  of  the  albumen  and 
fibrin.  Care  should  be  exercised,  however,  in  its  ad- 
ministration. 

Excessive  hemorrhage  will  sometimes  occur  from 
very  slight  wounds  ;  death  has  been  known  to  ensue 
from  simply  scarifying  the  gums.  Mr.  C.  desired 
the  removal  of  the  first  superior  molar.  The  gum 
was  separated  from  the  neck  of  the  tooth  with  the 
lancet,  in  the  usual  manner,  when  he  refused  to  have 


HEMORRHAGE.  357 

anything  further  done,  and  left  the  office,  there  being 
a  slight  discharge  of  blood  from  the  gum.  After  a 
few  hours,  the  hemorrhage  increased  so  as  to  cause 
alarm  to  the  friends.  The  patient  was  some  eight 
miles  from  a  dentist,  and  a  physician  of  rather  mode- 
rate skill  was  called  to  the  case.  He  probably  did  as 
well  as  he  knew  how,  but  failed  to  arrest  the  hemor- 
rhage, and  succeeded  in  convincing  the  friends  that 
no  one  else  could  do  any  better.  The  flow  of  blood 
continued  for  from  three  to  four  days,  proving  well- 
nigh  fatal,  but  at  last  abated,  and  the  patient  re- 
covered. In  this  case,  a  properly  directed  compress 
would  have  checked  the  bleeding  in  a  few  minutes. 

Another  case  :  Mrs.  T.  had  nine  teeth  removed. 
The  operation  was  not  followed  immediately  by  un- 
usual hemorrhage  ;  but,  within  two  or  three  hours, 
the  flow  of  blood  had  increased  to  an  alarming  ex- 
tent, so  as  to  run  from  the  mouth  in  a  continuous 
stream.  The  indications  were  that  the  patient  would 
soon  die.  She  had  become  very  weak.  On  exami- 
nation, the  blood  was  found  issuing  only  from  the 
socket  of  one  root  of  an  inferior  molar.  The  mouth 
and  socket  being  cleansed  of  blood  and  coagula,  it 
was  perceived  that  the  hemorrhage  was  from  a  small 
artery  at  the  bottom  of  the  socket,  spouting  out  in 
jets  with  the  pulsations.  The  treatment  consisted  in 
rolling  up  pledgets  of  cotton  very  tightly,  saturating 
them  with  creosote  and  tannin,  and  forcing  them  in 


358  ACCIDENTS    IN    THE    EXTRACTION    OF    TEETH. 

on  the  bottom  of  the  socket,  so  as  to  make  compres- 
sion upon  the  bleeding  vessel.  The  socket  was  then 
filled  up,  compression  made,  and  the  head  bandaged 
in  the  manner  already  described.  Thus  the  hemor- 
rhage was  immediately  checked,  and  no  recurrence 
ensued.  The  constitution  of  this  patient  was  of  a 
scorbutic  diathesis. 

Excessive  bleeding  often  does  not  occur  till  con- 
siderable time  after  an  operation  ;  and  it  may  come 
on  without  any  exciting  cause,  or  be  induced  by 
vigorous  muscular  exercise,  or  by  any  intense  mental 
excitement.  Everything  of  this  kind  should  be 
avoided,  where  there  is  a  predisposition  to  hemor- 
rhage, and  everything  invited,  that  would  tend  to 
maintain  the  equilibrium  of  the  circulation  and  the 
utmost  quiet. 

FRACTURE  OF  THE  ALVEOLUS. 

The  ordinary  fracture  of  the  alveolus  is  a  matter 
of  no  considerable  consequence,  if  it  receives  proper 
attention.  This  fracture  occurs  to  a  greater  or  less 
extent  under  the  following  circumstances:  first,  when 
there  is  great  divergence  of  the  fangs,  so  that  the 
tooth  cannot  pass  from  its  socket,  unless  one  or  more 
of  the  roots  are  broken  off,  or  the  alveolus  fractured  ; 
second,  where  the  tooth  is  forced  out  of  the  socket  at 
a  very  considerable  angle  with  its  axis ;  third,  where 


FRACTURE  OF  THE  ALVEOLUS.  359 

the  alveolus  is  very  firmly  attached  to  the  roots,  and 
is  very  thin  toward  the  points  of  these.  Usually,  the 
fracture  is  of  that  part  which  forms  the  socket  of  the 
tooth  removed ;  and  when  this  is  the  case,  it  is  of 
but  small  moment.  It  sometimes,  however,  extends 
far  beyond  this,  involving  the  alveolus  of  from  one  to 
four  of  the  adjacent  teeth,  and  causing  very  serious 
injury,  even  the  loss  of  the  teeth  themselves.  Ex- 
tensive fracture,  however,  is  far  less  liable  to  occur 
now,  than  when  less  perfect  instruments  were  em- 
ployed. When  the  key  was  in  such  general  use, 
extensive  fracture  of  the  alveolus  was  frequent;  but 
with  the  forceps,  it  is  comparatively  rare. 

When  an  accident  of  this  kind  does  occur,  all  of 
the  detached  portion,  whether  large  or  small,  should 
be  removed.  A  pair  of  bone  nippers  will  answer  for 
this  purpose.  If  there  is  much  attachment  to  the 
soft  parts,  it  should  be  dissected  off,  and  then  re- 
moved. If  such  fractured  portions  are  permitted  to 
remain,  inflammation,  and  oftentimes  sloughing  of  the 
gums,  will  ensue  ;  and  necrosis  of  the  bone  is  also 
sometimes  produced  by  detached  bone  remaining  in 
contact  with  the  living. 

Sometimes  extensive  fracture  occurs,  involving  the 
adjacent  bony  structure.  In  the  case  of  Mr.  W.,  in 
an  effort  to  remove  the  first  superior  molar,  the  outer 
wall  of  the  alveolus  was  separated  from  the  other 
teeth.     The  fracture  extended  almost    to    the  zygo- 


360  ACCIDENTS   IN   THE   EXTRACTION    OF   TEETH. 

matic  process,  and  detached  a  portion  of  the  floor  of 
the  antrum,  as  well  as  a  part  of  its  outer  wall.  After 
the  removal  of  this  detached  portion,  there  was  a 
considerable  external  depression,  that  very  much 
marred  the  form  and  symmetry  of  the  face. 

Fracture  of  the  alveolus  should  always  be  guarded 
against  as  carefully  as  possible.  It  always  makes  an 
unfavorable  impression  on  the  mind  of  the  patient, 
which  in  many  cases  no  explanation  can  obliterate. 
Whenever  the  accident  does  occur,  the  disagreeable 
knowledge  of  it  may,  if  practicable,  remain  a  secret 
with  the  operator. 

LACERATION    OF    THE    GUMS. 

The  gums  are  often  bruised  and  lacerated  with  the 
key  in  the  extraction  of  teeth.  But  this  accident 
seldom  happens  with  the  forceps ;  indeed,  never,  un- 
less the  gum  is  very  firmly  attached  to  the  neck  of 
the  tooth,  and  has  not  been  separated  with  the  lan- 
cet. The  gum  will  sometimes  be  lacerated  by  adher- 
ing to  a  piece  of  the  process,  while  the  tooth  is  drawn 
from  its  socket,  with  the  process  and  gum  attached. 
With  the  various  hooks  and  punches,  the  gums,  lips, 
and  cheeks  are  sometimes  wounded.  Accidents  of 
this  kind  are  to  be  prevented  by  placing  a  finger  of 
the  left  hand,  or  a  guard  made  of  a  roll  of  linen,  in 
front   of  the    instrument.     When    any   considerable 


BREAKING    TIIE    TEETH.  361 

portion  of  the  gum  is  lacerated,  the  detached  portion 
should  be  cut  off.  The  worst  consequences  from 
laceration  of  the  soft  parts  occur  where  there  is  a 
hemorrhagic  diathesis.  The  most  effectual  means 
of  preventing  accidents  of  this  kind  is  to  separate  the 
gum  perfectly,  and  guard  well  the  points  of  the 
instrument. 


BREAKING    THE    TEETH. 

This  is  an  accident  of  no  small  consequence,  and  is 
liable  frequently  to  occur  in  the  use  of  imperfect,  ill 
adapted  instruments,  or  in  the  unskillful  use  of  good 
ones.  It  is  of  very  common  occurrence  when  the  key 
is  employed  for  extracting,  even  in  the  hands  of  those 
who  claim  to  be  skilled  in  its  use.  And  with  forceps, 
too,  of  the  primitive  form,  the  teeth  were  so  fre- 
quently broken,  as  almost  to  preclude  their  use  as 
extracting  instruments.  This  accident  usually  occa- 
sions great  pain  to  the  patient,  as  well  as  protracts 
the  operation,  and  diminishes  his  confidence  in  the 
ability  of  the  operator.  One  such  accident  will 
create  more  prejudice  than  fifty  skillful  operations 
can  obliterate. 

In  all  cases  where  a  tooth  is  broken,  the  root,  if 
possible,  should  be  removed ;  for,  if  it  be  not,  con- 
tinuous or  periodical  pain,  inflammation,  alveolar 
abscess,  and  the  like  affections,  are  liable  to  ensue. 


362  ACCIDENTS   IN   THE   EXTRACTION    OF   TEETH. 

The  remark  is  often  made,  when  teeth  are  broken, 
that  the  gums  will  close  over  the  roots  and  thus 
effectually  protect  them,  and  no  disagreeable  conse- 
quences will  follow.  In  no  ordinary  case  will  the 
gums  unite  over  even  the  smallest  portion  of  root 
that  may  have  been  left  in  the  socket. 

REMOVAL    OF    A   WRONG    TOOTH. 

There  is  very  rarely  any  excuse  for  the  removal  of 
a  sound,  healthy  tooth  in  the  immediate  vicinity  of  a 
diseased  one,  unless  it  be  in  a  case  of  those  deep- 
seated,  hidden  affections  which  are  difficult  to  diag- 
nose. It  sometimes  happens,  however,  that  a  sound 
tooth  is  removed ;  and  when  a  mistake  of  this  kind 
is  made,  the  diseased  tooth  should  also  be  at  once 
removed,  and  then,  if  the  conditions  are  favorable, 
the  healthy  one  should  be  immediately  replaced. 
The  circumstances  most  favorable  for  such  replace- 
ment, are,  a  good  constitution  in  a  state  of  health, 
and  a  normal  condition  of  the  mouth,  especially  of 
the  gums  and  mucous  membrane,  so  that  the  attach- 
ment would  take  place  with  as  little  inflammation 
and  soreness  as  possible.  If  the  tooth  is  necessarily 
kept  out  of  the  mouth  many  minutes,  it  should  be 
placed  in  cold  water;  and  before  the  replacement, 
the  socket  should  be  thoroughly  cleansed  of  coagu- 
lum.     The  tooth  is  then  introduced,  pressed  firmly 


DISLOCATION    OF    THE    INFERIOR    MAXILLA.  363 

to  place,  and  allowed  to  remain  without  disturbance 
or  irritation,  till  the  attachment  has  become  com- 
plete. During  the  time  it  is  reuniting,  treatment 
may  be  required  to  counteract  inflammation.  Meager 
diet,  abstinence  from  stimulants,  and  quiet,  should 
always  be  recommended  in  the  case. 

This  operation  has  been  wholly  condemned  by  some 
very  good  dentists.  Dr.  Koecker  declares  that  it 
should  never  be  attempted.  But  numerous  success- 
ful cases,  well  attested,  give  assurance  that  it  may 
very  frequently  be  accomplished  with  the  most  satis- 
factory results.  Mr.  T.,  aged  15,  of  good  constitu- 
tion, and  in  good  health,  and  with  the  mouth  princi- 
pally in  a  normal  condition,  had  the  second  inferior 
bicuspid  of  the  left  side  removed  by  mistake,  the  first 
molar  being  the  offending  tooth.  The  former  was  at 
once  put  into  cold  water,  and  the  latter  forthwith 
extracted.  The  socket  of  the  bicuspid  was  then 
cleansed,  and  the  tooth  replaced.  There  was  slight 
soreness  for  a  few  days,  after  which  the  tooth  was 
found  to  have  made  a  firm  and  permanent  reattach- 
ment ;  and  from  that  time  to  this — sixteen  years — it 
has  remained  perfect,  and  is  now  as  healthy,  lifelike, 
and  valuable  as  any  other  tooth  in  the  mouth. 

DISLOCATION    OF    THE    INFERIOR    MAXILLA. 

The  dislocation  of  the  inferior  maxilla  is  an  acci- 


364  ACCIDENTS    IN   THE    EXTRACTION   OF   TEETH. 

dent  of  not  very  frequent  occurrence.  In  persons  of 
lax  muscles  and  with  large  mouths,  the  operation  of 
extracting  teeth  is  liable  to  produce  it ;  sometimes 
when  the  operation  is  on  the  upper  jaw,  but  more 
frequently  when  it  is  on  the  lower.  In  the  former 
case,  it  is  an  effect  of  the  patient's  effort  to  open  the 
mouth;  but  in  the  latter,  generally  that  of  the  move- 
ment of  the  jaw  by  the  instrument.  The  dislocation 
consists  in  a  downward  and  forward  movement  of 
one  or  both  of  the  condyles,  so  that  they  are  thrown 
out  of  their  sockets,  and  rest  in  front  of  the  anterior 
rim.  In  such  case,  the  mouth  is  distended  to  its 
utmost,  the  chin  thrown  down  on  the  breast,  and 
deglutition  and  speech  rendered  impossible.  Some- 
times but  one  condyle  will  be  thrown  out ;  in  which 
case  the  jaw  is  thrown  downward  and  to  one  side. 

This  accident  seldom  or  never  occurs  with  patients 
who  have  small  months  or  firm  muscles.  When  it 
does  happen,  however,  the  dislocation  should  be 
promptly  reduced.  Of  the  various  methods  of  accom- 
plishing this  reduction,  the  one  most  commonly  em- 
ployed, which  is  very  efficient,  is  as  follows  :  if  both 
condyles  are  dislocated,  place  corks,  or  some  similar 
substance,  between  the  superior  and  the  inferior  molar 
teeth  of  both  sides  ;  and  then,  with  the  fingers  of 
both  hands,  make  firm,  steady  pressure  on  the  chin 
upward  and  backward,  thus  shoving  the  condyles 
downward   and   backward   into  their  proper  places. 


SYNCOPE.  3G5 

If  but  one  condyle  is  out,  the  cork  should  be  applied 
only  on  that  side,  and  in  the  same  manner  already 
directed.  An  other  method  is,  to  substitute  the 
thumbs  of  the  operator  for  the  corks,  placing  them 
in  the  same  position  between  the  teeth,  and  manipu- 
lating with  the  fingers  on  the  chin,  as  before.  The 
patient  should  be  placed  in  a  recumbent  position  for 
the  operation.  An  other  method  is,  to  make  down- 
ward and  backward  pressure  on  the  coronoid  process, 
and  in  this  manner  cause  the  condyles  to  glide  into 
their  places.  This  accomplishes  the  reduction  with- 
out taking  hold  of  the  jaws,  or  placing  a  fulcrum 
between  them. 

This  accident  is  far  more  liable  to  occur  the  second 
time  in  the  same  case.  In  extracting  the  lower  molar 
teeth  for  one  who  has  suffered  a  dislocation,  or  is  pre- 
disposed to  it,  the  lower  jaw  should  be  very  firmly 
supported  with  the  left  hand ;  or,  the  accident  may 
be  prevented  by  placing  a  bandage  under  the  chin, 
and  over  the  head,  so  that  the  mouth  can  not  be 
opened  to  its  furthest  extent ;  and  this  is  the  surest 
method.  In  all  cases  after  an  accident  of  this  kind, 
the  patient  should  abstain  from  solid  food  for  a  few 
days,  or  at  least  till  the  soreness  is  abated,  and  avoid 
everything  promotive  of  inflammation. 

SYNCOPE. 

Syncope,  or  fainting,  is  frequently  brought  on  by 


366  ACCIDENTS    IN    THE    EXTRACTION    OF   TEETH. 

extraction  of  the  teeth,  and  even  by  other  operations 
upon  them ;  indeed,  it  is  sometimes  produced  simply 
by  cutting  the  gums,  or  by  the  sight  of  blood,  or,  in 
some  instances,  by  dread  of  the  operation.  It  con- 
sists in  an  intermission  of  the  heart's  action,  and 
consequently  irregularity  of  the  circulation  of  the 
blood,  accompanied  with  a  temporary  suspension  of 
the  functions  of  the  brain  and  a  loss  of  consciousness. 
Difficult  or  suspended  respiration,  lividness  of  the 
skin,  and  inability  to  move,  are  the  external  indica- 
tions of  the  condition.  There  are  no  constitutional 
appearances  known,  by  which  a  predisposition  to 
syncope  can  be  determined  :  persons  of  all  apparent 
conditions  and  peculiarities  are  subject  to  it.  The 
most  strong,  robust,  and  healthy  sometimes  faint 
under  the  most  trivial  influences;  while  others,  of 
the  weakest  and  feeblest  constitutions,  can  not  be 
brought  into  this  condition  by  any  ordinary  means; 
so  that  nothing  can  be  predicated  of  appearances  as 
to  such  predisposition.  The  fainting  may  occur  once 
or  twice  in  the  same  case,  even  under  the  most  sim- 
ple operation,  owing  to  some  temporary  condition  of 
the  system,  and  never  happen  again  under  any  cir- 
cumstances whatever. 

It  sometimes  comes  on  before,  sometimes  after,  and 
sometimes  during,  the  operation.  There  is  greater 
liability  to  it  after  a  recent  meal  than  after  digestion 
is  completed,  since  the  nervous  energy,  during  diges- 


SYNCOPE.  367 

tion,  is  directed  to  the  stomach  and  its  appendages, 
and  thus  the  circulating  apparatus  has  less  of  nervous 
force. 

The  frequent  occurrence  of  syncope  indicates  a 
constitutional  predisposition  to  it,  and  may  enable 
the  operator  to  anticipate  it  to  some  extent,  by  the 
aid  of  stimulants,  such  as  brandy,  or,  what  is  in 
some  respects  preferable,  a  galvanic  current.  The 
patient  subject  to  such  affection,  should  be  placed, 
for  an  operation,  as  nearly  as  practicable  in  a  recum- 
bent position — especially  for  the  extraction  of  teeth 
— and  his  mind  kept  as  tranquil  as  possible. 

To  restore  the  patient  from  syncope,  place  him  in 
a  horizontal  position,  the  head  quite  as  low  as  the 
body,  and  apply  volatile  stimulants  to  the  nostrils, 
and  dash  water  on  the  face  and  chest.  All  compres- 
sion should  be  removed  from  the  body,  especially 
from  the  chest,  as  it  would  constrain  the  action  of 
the  respiratory  muscles.  This  remark  is  peculiarly 
applicable  to  female  patients.  This  treatment  will 
usually  be  quite  sufficient  to  effect  a  rapid  reaction 
and  resuscitation. 


CHAPTER    XIII. 

ANESTHETICS. 
ETHER — CHLOROFORM. 

Sulphuric  ether  was  the  first  agent  successfully 
employed  for  producing  insensibility  to  pain  during 
surgical  operations.  It  was  brought  to  the  notice  of 
the  profession  in  1846  by  Dr.  W.  G.  L.  Morton.  The 
mode  of  administering  it  is,  by  inhalation  of  the 
vapor  j  and  it  produces  its  effects  in  a  short  time, 
depending  on  the  quality  of  the  ether,  the  amount  of 
air  introduced  with  it,  and  the  susceptibility  of  the 
patient.  A  complicated  instrument,  denominated  an 
inhaler,  was  first  employed  for  its  administration ;  but 
it  soon  became  apparent  that  this  was  not  at  all  ne- 
cessary, and  that  simpler  methods  were  preferable, 
because  more  easily  regulated  and  adapted  to  circum- 
stances. The  best  method  is,  to  inhale  it  from  a 
sponge  or  napkin,  since,  in  this  way,  the  admission 
of  the  air  can  be  controlled  entirely  by  the  will  of  the 
operator,  graduating  it  to  the  requirements  of  the 
case. 


ETHER — CHLOROFORM.  369 

During  the  administration,  the  patient  should  be  in 
a  reclining  posture ;  though  it  is  held,  by  much  good 
authority,  that  a  horizontal  position  is  the  safest, 
because,  in  that,  the  force  of  the  circulation  is  most 
nearly  equalized.  In  the  administration  of  general 
anesthetics,  the  circulation  is  always  more  or  less 
affected.  It  is  an  opinion  very  generally  received, 
and  probably  correct,  that,  where  there  is  functional 
derangement  of  the  heart,  lungs,  or  brain,  general 
anesthesia  should  not  be  employed.  This  opinion, 
however,  is  perhaps  derived  more  from  analogy  than 
from  actual  observation.  It  is  true  that,  other  things 
being  equal,  the  liability  to  injury  in  such  case  would 
be  greater;  but  the  danger  with  both  ether  and  chlo- 
roform is,  that  there  are  cases  in  which  there  is  an 
undefinable  and  undetectable  idiosyncracy,  or  malsus- 
ceptibility  of  its  influence,  to  a  great  extent  indepen- 
dent of  pathological  conditions. 

The  patient  having  been  placed  in  a  comfortable 
position,  and  his  mind  freed  as  far  as  possible  from 
apprehension,  he  should  be  directed  to  breathe  tran- 
quilly by  full  inspirations,  carefully  guarding  against 
any  compression  of  the  chest,  so  as  to  allow  the  re- 
spiratory muscles  free  play.  During  the  administra- 
tion of  the  anesthetic,  a  strict  watch  must  be  main- 
tained over  the  patient,  having  reference  to  the  fol- 
lowing points  :  the  breathing  should  be  free  and  easy, 
without  irritation  of  the  throat  or  bronchia;  the  skin 


370  ANESTHETICS. 

should  not  become  blanched,  but  should  retain  a 
florid,  lively  color ;  but  the  great  criterion  is  the 
pulse,  and  the  indications  given  here  should  be  strictly 
observed  and  obeyed.  In  order  that  the  operator 
may  follow  every  indication,  he  should  be  familiar 
with  the  manifestations  of  the  pulse  in  different  con- 
stitutions, and  under  different  circumstances.  During 
the  administration  of  ether  or  chloroform,  the  pulse 
usually  becomes  more  frequent ;  but  it  should  not  be 
much  accelerated,  nor  its  strength  and  fulness  be 
much  diminished.  Enfeebled  or  irregular  pulse  should 
in  all  cases  be  regarded  as  a  warning;  and  if  the 
feebleness  and  irregularity  be  very  marked,  the  ope- 
rator should  desist.  In  some  instances,  death  has 
occurred  after  a  few  inhalations;  but  perhaps  only  in 
the  use  of  chloroform.  This  fact  intimates  that  the  first 
effectsof  the  administration  should  be  very  closely  noted. 
The  degree  to  which  the  anesthesia  should  be  car- 
ried, is  a  matter  about  which  there  is  much  diversity 
of  opinion.  Every  condition  of  it,  from  that  of  simple 
allayed  irritability  to  that  of  complete  insensibility 
and  unconsciousness,  has  its  advocates.  But  the 
extent  to  which  the  administration  may  be  carried, 
will  be  suggested  by  the  indications  already  referred 
to,  and,  if  these  are  unfavorable,  should  be  determined 
at  once.  Mere  nausea,  however,  without  any  other 
unfavorable  symptom,  is  not  a  counter-indication  in 
the  use  of  ether  or  chloroform. 


ETHER — CHLOROFORM.  371 

The  method  of  administering  chloroform  is  the  same 
as  that  for  ether,  except  that,  in  the  use  of  the  former, 
more  care  and  closer  observation  are  required.  Chlo- 
roform is  more  rapid  and  powerful  in  its  action  than 
ether,  and  hence  more  liable  to  do  injury;  but,  inde- 
pendently of  this  fact,  it  is  generally  believed  that  the 
former  is  less  safe  than  the  latter,  when  taken  into 
the  system,  especially  by  inhalation.  A  mixture  of 
ether  and  chloroform,  or  chloric  ether — usually  equal 
parts  of  chloroform  and  ether,  but  the  proportions  are 
sometimes  varied — is  used  by  some ;  the  object  being 
to  secure  greater  promptness  than  with  ether  alone, 
and  incur  less  danger  than  with  chloroform ;  and  it 
is  probable  that  a  mutual  compensation  in  these  re- 
spects is  thus  to  be  attained. 

If  either  chloroform  or  ether  has  been  administered 
to  entire  unconsciousness,  the  patient  should  be  per- 
mitted to  pass  out  of  the  condition  spontaneously; 
for,  after  such  a  revival,  there  will  be  less  liability  to 
unpleasant  feelings,  as  headache,  depression,  and 
nausea.  The  fingers  of  the  person  administering  the 
chloroform  should  be  kept  on  the  carotid,  since  the 
state  of  the  circulation  will  be  better  recognized  by 
this  than  by  the  radial  artery,  and  it  is  a  more  con- 
venient point  for  observation.  In  favorable  cases,  it 
is  preferable  to  continue  the  inhalation  till  there  is  a 
muscular  relaxation. 

When   a  condition  arises  in  which  respiration  is 


372  ANESTHETICS. 

suspended,  and  the  circulation  partially  or  altogether 
stopped — a  condition  of  imminent  peril — active  mea- 
sures must  be  resorted  to  for  the  patient's  restoration. 
Efforts  must  be  directed  to  a  recovery  of  the  circula- 
tion, by  friction,  motion,  etc.;  but  to  restore  the 
respiration,  is  the  first,  immediate,  imperative  consi- 
deration. Any  or  all  of  the  ordinary  methods  of  re- 
establishing suspended  respiration  may  be  employed. 
Cold  water  should  be  dashed  in  the  face,  and  on  the 
throat  and  chest,  and  volatile  stimulants  applied  to 
the  nostrils;  the  glottis  should  be  titillated  with  a 
feather,  or  some  such  implement,  to  excite  it  to  action ; 
and  artificial  respiration,  by  some  approved  method, 
should  be  at  once  adopted.  The  galvanic  current, 
too,  may  be  brought  into  requisition,  to  excite  the 
respiratory  muscles  to  action,  and  to  act  also  upon  the 
circulation.  In  all  cases  of  accident  of  this  kind, 
prompt  and  efficient  measures  should  be  immediately 
taken  ;  for  a  delay  of  a  few  moments  may  be  attended 
with  fatal  results. 

LOCAL    ANESTHESIA. 

Because  of  the  frequently  prejudicial  and  sometimes 
fatal  consequences  to  which  systemic  anesthesia  is 
liable,  local  anesthesia  has  been  much  brought  into 
requisition  ;  among  the  agencies  for  producing  which 
may  be  first  reckoned 


LOCAL   ANESTHETICS.  373 

Congelation. — Of  the  various  freezing  mixtures  and 
implements  applicable  for  this  purpose,  the  apparatus 
chiefly  used,  and  perhaps  the  best  yet  brought  to  the 
notice  of  the  profession,  consists  of  two  parts  of  pul- 
verized ice  and  one  of  salt,  applied  by  means  of  an 
instrument  of  the  following  description  :  a  vulcanized 
India-rubber  tube,  about  five  inches  long  and  one  inch 
in  diameter,  closed  at  its  superior  extremity  by  a 
screwcap,  and  open  at  its  inferior,  which  latter  is 
slightly  enlarged  and  cut  out,  so  as  to  leave  two  lips 
to  reach  down  on  the  sides  of  the  tooth ;  within  the 
tube,  a  follower  and  a  spiral  spring,  the  latter  forcing 
the  former  down  to  the  open  end.  When  this  instru- 
ment is  to  be  used,  tie  a  piece  of  oiled  silk  or  mem- 
brane loosely  over  its  inferior  end,  fill  it  expeditiously 
twothirds  full  with  the  ice  and  salt,  prepared  as 
above,  adjust  the  follower  and  spring  in  place,  screw 
on  the  cap,  and  apply  at  once.  The  sac  of  the  in- 
strument is  to  be  pressed  and  worked  gradually  down 
till  it  invests  a  portion  of  the  gum  on  each  side  of  the 
tooth  to  be  extracted.  As  the  ice  melts  in  the  sac, 
the  follower  forces  the  unmelted  portion  down  next  to 
the  tooth  and  gum.  The  application  should  be  con- 
tinued from  one  to  three  minutes,  or  till  the  margin 
of  the  gum  is  congealed — as  will  be  indicated  by  its 
hardness  and  whitened  appearance — and  then  the 
tooth  should  be  extracted  as  expeditiously  as  possible, 
though  with  all  the  ordinary  skill  and  care. 


374  ANESTHETICS. 

If  the  contiguous  teeth  are  sound,  and  not  to  be 
extracted,  they  must  be  protected  as  far  as  possible 
from  the  influence  of  the  application — as  they  may 
be,  by  having  their  crowns  enveloped  in  thin  sheets 
of  wax,  oiled  silk,  or  any  other  substance  that  is  a 
nonconductor,  and  is  not  too  bulky.  Where  some 
such  protection  is  not  afforded,  great  injury  is  liable 
to  ensue. 

If  the  tooth  to  be  extracted  is  sensitive,  the  tem- 
perature should  be  reduced  by  holding  in  the  mouth 
cold  water,  and  finally  a  piece  of  ice  ;  and  immediately 
after,  the  instrument  should  be  applied.  When  the 
pulp  of  the  tooth  is  exposed,  the  application  would  be 
intolerable.  In  such  case,  it  has  been  recommended 
first  to  apply  arsenic  for  twentyfour  hours  to  the  ex- 
posed pulp.  This  method  of  procedure,  however,  will 
be  found  wholly  impracticable. 

Under  the  full  influence  of  the  freezing  mixture,  the 
circulation  in  the  part  is  wholly  arrested,  and  the 
sensibility  entirely  obtunded,  so  that  the  operation, 
properly  performed,  produces  no  pain.  In  the  extrac- 
tion, the  gum,  so  far  as  congealed,  may,  if  necessary, 
be  embraced  by  the  forceps  and  broken  away  without 
pain.  After  the  operation,  cold  water  or  ice  should  be 
applied  to  the  part,  to  prevent  a  too  rapid  reaction, 
which  would  be  very  painful,  but  which,  thus  gra- 
duated, occasions  but  slight  pain,  and  in  some  cases 
none  at  all. 


EXTRACTION    BY    ELECTRO-MAGNETISM.  375 

The  aim  in  all  cases  should  be  to  produce  congela- 
tion to  the  very  point  of  the  root ;  for,  without  this, 
the  extraction  will  cause  pain.  And  it  is  far  more 
difficult  to  effect  this  object  where  only  the  root,  than 
where  the  crown  is  remaining ;  for  this  serves  as  a 
conductor.  In  the  former  case,  however,  a  screw  or 
iron  wire  may  be  introduced  into  the  root,  and  left 
projecting,  to  serve  as  a  conductor.  But  in  some 
cases,  especially  in  those  of  roots,  it  is  improper  to 
attempt  the  employment  of  congelation  at  all.  The 
practicability  of  a  desirable  result  will  depend  much 
upon  the  skill  and  tact  of  the  operator,  and  the  sus- 
ceptibility of  the  parts.  In  patients  of  full  habit  and 
active  circulation,  it  is  very  difficult  to  produce  insen- 
sibility by  congelation  ;  and  in  such  cases  great  pain 
usually  attends  its  application. 

EXTRACTION    BY    ELECTRO-MAGNETISM. 

The  employment  of  electro-magnetism  in  the  ex- 
traction of  teeth  is  of  recent  date,  it  being  only  about 
a  year  since  its  general  introduction  to  the  dental  pro- 
fession. In  this  time,  however,  it  has  been  exten- 
sively used.  There  is  a  great  diversity  of  opinion  as 
to  its  efficiency  for  relieving  pain  ;  for,  while  some 
have  been  disposed  to  assume  that,  when  properly 
employed,  it  would,  in  the  generality  of  cases,  miti- 
gate pain,  and,  in  the  majority,  obviate  it  altogether, 
others,   after  having  thoroughly  tested   it,   as    they 


376  ANESTHETICS. 

affirm,  maintain  that  it  does  not  produce  insensibility 
to  any  appreciable  extent,  and  consequently  does  not 
relieve  the  pain,  but  that,  at  most,  it  only  complicates 
the  sensations,  the  pain  of  the  tooth-drawing  becom- 
ing involved  in  the  confusion  of  other  feelings,  so  that 
the  patient  can  hardly  decide  whether  he  has  been 
definitely  hurt  or  not ! 

In  using  this  agent  for  the  process  of  extracting 
teeth,  the  susceptibility  of  the  patient  to  its  influence 
must  be  carefully  regarded.  Some  persons  are  so 
peculiarly  constituted  that  an  electric  current  is  al- 
most intolerable  to  them ;  while  others  will  receive  a 
strong  current  with  pleasurable  sensations.  To  the 
former,  the  electricity  would  be  as  painful  as  the  ex- 
traction of  the  tooth  ;  but  to  the  latter,  when  properly 
applied,  it  mitigates,  and  in  many  cases  altogether 
obviates,  the  pain.  The  reason  of  this  difference  in 
its  action  is  not  very  clearly  understood.  Several 
theories  in  regard  to  it  have  been  advanced,  but  none 
of  them  sufficiently  plausible  to  challenge  conviction. 

Again,  the  manner  in  which,  and  the  condition  of 
the  parts  to  which,  this  agency  is  applied,  are  to  be 
closely  observed.  Where  there  is  acute  periostitis, 
an  electric  current,  even  though  feeble,  would  produce 
intense  pain,  and  should  not  be  applied ;  though,  in 
such  cases,  it  has  been  suggested  that  an  application 
of  the  charged  sponge  to  the  gums  will  produce  insen- 
sibility. 


APPLICATION.  377 


APPLICATION. 


The  method  of  application  is  very  simple.  Any 
ordinary  battery,  of  convenient  form,  may  be  em- 
ployed for  this  purpose.  It  should  be  uniform  in  its 
action,  and  the  vibration  as  short  as  possible.  The 
common  zinc-and-copper  battery,  with  the  sulphate- 
of-iron  solution,  is  perhaps  the  most  convenient  and 
safe.  One  pole  of  the  battery — no  matter  which — is 
attached  to  the  forceps,  and  the  other  to  a  handle  of 
size  and  form  convenient  for  the  patient  to  grasp.  To 
ascertain  his  susceptibility,  the  current  should  always 
first  be  tested  on  the  patient,  by  placing  the  handle 
and  the  forceps  one  in  each  of  his  hands,  and  letting 
it  on  first  feebly,  and  then  gradually  increasing  it  till 
he  experiences  the  sensation  just  beyond  the  elbows; 
when,  finally,  it  is  to  be  slightly  weakened.  The 
gum  having  been  separated,  the  forceps,  with  its  ap- 
pendages, is  adjusted  to  the  tooth,  the  connection 
made  by  placing  the  handle  in  the  patient's  hand,  and 
the  tooth  at  that  moment  removed.  It  has  been  re- 
commended by  some  to  place  the  forceps  on  the  tooth, 
and  complete  the  circuit,  as  above,  with  the  current 
very  feeble,  and  then  gradually  increase  it  to  the 
proper  force  for  the  operation.  In  some  cases,  per- 
haps, this  would  be  the  preferable  mode. 

An  other  method  of  producing  insensibility  by  an 


378  ANESTHETICS. 

electric  current  is,  to  place  two  moistened  sponges, 
connected  with  the  two  poles  of  the  battery,  on  the 
gum,  one  on  each  side  of  the  tooth,  keep  them  there 
a  few  moments,  and  then  operate.  This  method, 
however,  has  not  yet  been  sufficiently  tested  to  ascer- 
tain its  merits. 


INDEX. 


Atrophy,  29. 

cause  of,  30. 
Amalgam,  88. 
Adhesive  foil,  154. 
Actual  cautery,  23G. 
Arsenious  acid,  218. 

application  of,  239. 
Alveolar  abscess,  259. 

treatment  of,  261. 
Attachment  of  an  artificial  crown,  275. 
Accidents  in  the  extraction  of  teeth,  347. 
Anesthetics,  368. 
Application  of  electro-magnetism,  377. 

Broaches,  101. 
Bur  drill,  96. 
Block  filling,  148. 
Breaking  of  the  teeth,  361. 

Chloroform,  368. 
Chemical  abrasion,  36. 

cause  of,  37. 
Comparative  liability  of  the  teeth  to  decay,  62. 


380  INDEX. 

Caries  of  the  teeth,  41. 

causes  of,  51. 

exciting  causes  of,  55. 

consequences  of,  63. 

treatment  of,  66. 
Crystal  gold,  86,  158,  177. 
Classification  of  decayed  cavities,  166. 
Creosote  or  carbolic  acid,  214. 
Chloride  of  zinc,  216. 
Conditions  to  be  observed  in  extraction  of  the  teeth,  342. 

Deposits,  18. 

points  of,  20. 
Denuding,  34. 
Drills,  96. 
Drill  stocks,  100. 
Drying  cavities,  139. 
Destruction  of  the  pulp,  231. 
Dislocation  of  the  inferior  maxillar,  363. 

Ether,  368. 

Extraction  preparatory  to  the  insertion  of  artificial  dentures,  340. 

Exostosis,  31. 

effects  of,  33. 

cause  of,  33. 
Examination  of  decays,  125. 
Excavators,  101. 

manufacture  of,  105. 
Exposed  pulps,  221. 

treatment  of,  22.'!. 

destruction  of,  231. 
Extraction  of  teeth,  285,  319. 
Extracting  instruments,  294. 
Elevators,  311. 
Extraction  by  electro-magnetism,  315. 


INDEX.  381 

Extraction  of  the  inferior  incisors,  331. 

Filling  teeth,  124. 

examination  of,  125. 

opening  cavities,  126. 

drying  cavities,  139. 

removal  of  decay,  128. 
Forming  cavities,  131. 
Forming  blocks,  149. 
Finishing  fillings,  162. 
Filling  by  classes  and  modifications,  168. 
Filling  with  foil,  173. 

Filling  large  cavities  on  the  labial  surfaces  of  superior  incisors,  -04. 
Filling  pulp-cavities  and  canals,  244. 
Filling  the  crown,  272. 
Forceps,  299. 
Fracture  of  the  alveolus,  358. 

Green  tartar,  24. 

treatment  of,  26. 
General  remarks  on  filling,  71. 
Gold,  83. 

General  remarks  on  extraction,  285. 
Gum  lancet,  315. 

Hemorrhage,  348. 

Heavy  cutting-instruments,  74. 

Inferior  molars,  extraction  of,  3.",."). 
Inferior  dens  sapientia>,  extraction  of,  339. 
Inferior  bicuspids,  extraction  of,  334. 
Introduction,  17. 
Irregularity  of  the  teeth,  27. 

effects  of,  28. 
Instrument.',  for  filling,  91. 
Introducing  the  filling,  142. 
Introducinfr  the  blocks,  151. 


382  INDEX. 

Indications  for  extraction,  292. 
Inferior  cuspids,  extraction  of,  332. 

Lead  for  filling,  79. 
Laceration  of  the  gums,  360. 
Local  anesthesia,  372. 

Materials  for  filling,  75. 

metallic,  75. 

non-metallic,  91. 
Manufacture  of  excavators,  105. 
Mode  of  using  the  file,  114. 
Metallic  pivots,  279. 

Necrosis  of  the  teeth,  38. 

causes  of,  39. 
Nitrate  of  silver,  214. 

Opening  cavities,  126. 

Platinum,  82. 

Plugging  instruments,  106. 

Pathological  conditions,  206. 

Potential  cautery,  237. 

Preparing  the  teeth  for  filling,  251. 

Pivot  teeth,  268. 

Pellets  for  filling,  154. 

Removal  of  the  dens  sapientiae,  329. 
Removal  of  decay,  128. 
Removal  of  a  wrong  tooth,  362. 

Silver,  81. 

Separation  of  the  teeth,  118. 

Special  cases,  199. 

Superior  cuspids,  extraction  of,  321. 

Superior  bicuspids,  extraction  of,  323. 

Syncope,  365. 


INDEX.  383 

Tartar,  18. 

origin  of,  19. 

effects  of,  21. 

method  of  removing,  22. 
Tin,  80. 
The  file,  111. 

use  of,  113. 
The  palatal  portion  of  the  crown  broken  away,  leaving  the  outer  portion 

standing — nerve  not  exposed,  200. 
Treatment  of  inflamed  dentine,  210. 
Tannin  or  Tannic  Acid,  213. 
Terchloride  of  gold,  217. 
The  key,  295. 

The  method  of  lancing  the  gums,  317. 
Treatment  of  hemorrhage,  350. 

Various  preparations  of  gold,  85. 


m 


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